Roth 10e NCLEX Chapter 9

MULTIPLE CHOICE 1. A client comes to the clinic experiencing thirst, dizziness, nausea, headache, and profuse sweating after running a 10K race on a day when the outside temperature was 98 degrees F. What stage of heat illness should the nurse suspect? a. heat cramp c. heat fatigue b. heat exhaustion d. heat stroke ANS: B The four stages of heat illness are (1) heat fatigue, which causes thirst, feelings of weakness, or fatigue (2) heat cramp which causes leg cramps and thirst (3) heat exhaustion, which causes thirst, dizziness, nausea, headache, and profuse sweating (4) heat stroke, which involves fever and could produce brain and kidney damage. PTS: 1 REF: Dehydration

2. An otherwise healthy client with a diagnosis of schizophrenia presents to the clinic with significant edema. The nurse knows that there are several conditions that can cause excessive accumulation of fluid in the body. What should the nurse conclude is the most likely cause of edema in this patient? a. congestive heart failure c. hypoproteinemia b. excessive drinking d. renal failure ANS: B Some conditions cause an excessive accumulation of fluid in the body. It occurs when more water is taken in than is used and excreted, and edema results. Excessive water drinking is a recognized characteristic of schizophrenia. Other conditions that cause edema are hypothyroidism, congestive heart failure, hypoproteinemia, some infections, some cancers, and some renal conditions. PTS: 1 REF: Excess Water Accumulation

3. A clients lab results indicate that the client is acidotic. The nurse knows of several conditions that can cause acidosis. Which of the following will the nurse suspect is the cause of the clients acidosis? a. a loss of hydrochloric acid c. severe vomiting b. renal failure d. too many antacid tablets

ANS: B Upsets in acid-base balance can occur in some disease conditions. Renal failure, uncontrolled diabetes mellitus, starvation, or severe diarrhea can cause acidosis. Alkalosis can occur when the body has suffered a loss of hydrochloric acid from severe vomiting or has ingested too much alkali, such as too many antacid tablets. PTS: 1 REF: Acidosis and Alkalosis

4. A healthy client expresses concern about maintaining proper electrolyte balance in the body. The nurse learns that this concern is rooted in the clients experience with her elderly parents who frequently suffer from electrolyte imbalances. Which of the following statements about electrolyte balance could the nurse make to the client? a. Electrolyte balance is not critical to health. c. Healthy people who are eating a balanced

diet need not be concerned about electrolyte balance. b. Electrolyte imbalances cannot be avoided d. Try not to eat fresh fruit each day. because the body doesnt have adequate mechanisms to regulate electrolyte balance. ANS: C Healthy people eating a balanced diet need not be concerned about fluid, electrolyte, or acid-base balance, as the body has intricate maintenance systems for all. Loss of electrolyte balance can result in death. Fruit is an important part of a balanced diet. PTS: 1 REF: Dehydration; summary

5. The nurse is teaching a health class at a local school. A student asks how long a person can live without water. Which of the following answers would the nurse give? a. 1-7 days c. 15-20 days b. 10-14 days d. 30-45 days ANS: B Although humans can live about 30-45 days without food, it is possible to live only 10-14 days without water. PTS: 1 6. The nurse is teaching a client about the need for adequate fluid intake and is explaining that there are both sensible and insensible losses of fluids from the body. Which of the following will the nurse say are sources of sensible fluid loss? a. Feces c. respiration b. perspiration d. urine ANS: D MULTIPLE RESPONSE 1. An otherwise healthy but dehydrated client requires rehydration. What factors that lead to fluid imbalances, other than illness, could the nurse discuss with this client? Select all that apply. a. excessive caffeine intake d. exposure to sun or high temperatures b. excessive use of alcohol e. fad diets c. exercise without fluid replacement f. fasting ANS: A, B, C, D, E, F REF: Fluid and Electrolyte Balance PTS: 1 PTS: 1 REF: Fluid and Electrolyte Balance

2. The nurse is counseling a client who was recently treated for dehydration. The nurse is teaching the client the signs of dehydration so the client can take in fluids and avoid dehydration in the future. What will the nurse say are the signs and symptoms of dehydration? Select all that apply. a. dry skin d. low body temperature b. high blood pressure e. mental disorientation c. low blood pressure f. Thirst ANS: A, C, E, F Symptoms of dehydration include low blood pressure, thirst, dry skin, fever, and mental disorientation. PTS: 1 REF: Dehydration

3. The nurse is counseling parents about the need to keep their infant well hydrated. What information could the nurse share with client so the client would understand the importance of keeping the infant well hydrated? Select all that apply. a. A loss of 10 % of body water can cause d. Infants are at high risk of dehydration serious problems. when fever, vomiting, and diarrhea occur. b. A loss of 10% of body water will occur on e. There are no risks associated with fluid most warm days and should be expected. loss until 40% of body water has been lost. c. A loss of 20% of body water can cause f. Thirst is not a reliable indicator of when circulatory problems and death. the body needs water. ANS: A, C, D, F Infants are at high risk of dehydration when fever, vomiting, and diarrhea occur. A loss of 10 % of body water can cause serious problems. A loss of 20% of body water can cause circulatory problems and death. Infants, for example, are at high risk of dehydration when fever, vomiting, and diarrhea occur. The thirst sensation often lags behind the bodys need for water, especially in the elderly, children, athletes, and the ill. Thirst is not a reliable indicator of when the body needs water. PTS: 1 REF: Dehydration

4. To emphasize the need for adequate fluid intake, the nurse is teaching a client about the functions of water in the body. Which of the following could the nurse say are functions of water in the body. Select all that apply. a. acts as lubricant and cushion around joints d. participates in many chemical reactions in the body b. assists in regulation of body temperature e. provides transport for nutrients c. helps hair grow f. serves as a solvent for minerals, vitamins, amino acids, glucose ANS: A, B, D, E, F Water participates in many chemical reactions; serves as solvent for minerals, vitamins, amino acids, glucose, and other small molecules; provides transport for nutrients and wastes via the blood and lymphatic systems; acts as lubricant and cushion around joints; assists in regulation of body temperature; bathes eyes, spinal cord; makes up the amniotic fluid that surrounds the fetus. PTS: 1 REF: Introduction