which of the following components is associated with hypertonic dehydration

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. Which of the following components is associated with hypertonic dehydration?

A. Plasma sodium levels above 150 mEq/L
B. Fluid moves from extracellular space to intracellular space
C. Water loss is greater than electrolyte loss
D. Physical signs and symptoms are grossly apparent

Correct answer: C

Rationale: The correct answer is 'Water loss is greater than electrolyte loss.' In hypertonic dehydration, there is a higher loss of water compared to electrolytes, leading to elevated concentrations of electrolytes in the body. This condition is characterized by plasma sodium levels above 150 mEq/L. As water moves from the extracellular space to the intracellular space, it results in cellular dehydration. Choice A is incorrect because the plasma sodium levels associated with hypertonic dehydration are typically above 150 mEq/L, not between 130 and 150 mEq/L. Choice B is incorrect as fluid moves from the extracellular space to the intracellular space in hypertonic dehydration. Choice D is incorrect because physical signs and symptoms may not always be grossly apparent in hypertonic dehydration.

2. Becky is a 17-year-old type I diabetic who has been admitted for her third episode of diabetic ketoacidosis (DKA) since being diagnosed last year. She states that she hates feeling different from her friends and refuses to take her insulin as recommended. What would be the most helpful action for Becky?

A. Scolding her for not taking her insulin
B. Recommending that she use an insulin pump
C. Contacting the local support group for diabetic teens
D. Telling her parents they must provide more strict oversight

Correct answer: C

Rationale: Contacting the local support group for diabetic teens would be the most helpful action for Becky. By reaching out to see if another diabetic teenager could provide support, Becky would have the opportunity to connect with someone in her peer group who faces similar challenges. This connection can help reduce her sense of isolation and the feeling of being 'different.' Choice A, 'Scolding her for not taking her insulin,' is inappropriate and could further alienate Becky. It does not address the underlying emotional issues driving her behavior. Choice B, 'Recommending that she use an insulin pump,' does not directly address Becky's emotional struggle with feeling different from her friends. While an insulin pump may be a helpful tool, it does not tackle the root cause of her non-compliance. Choice D, 'Telling her parents they must provide more strict oversight,' focuses on imposing stricter control without addressing Becky's emotional needs or offering peer support, which may not be effective in improving her insulin adherence in the long term.

3. What action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?

A. Providing supportive care to patients diagnosed with pertussis
B. Teaching family members about the importance of careful handwashing
C. Teaching patients about the necessity of adult pertussis immunizations
D. Encouraging patients to complete the prescribed course of antibiotics

Correct answer: C

Rationale: The most effective action by the nurse to decrease the spread of pertussis in a community setting is to teach patients about the necessity of adult pertussis immunizations. The increased rate of pertussis in adults is often attributed to waning immunity after childhood immunization. Immunization is highly effective in protecting communities from infectious diseases. While teaching about handwashing is important for overall infection control, pertussis is primarily spread through respiratory droplets and contact with secretions. Providing supportive care does not significantly impact the disease course or transmission risk. Encouraging completion of antibiotics may help reduce transmission, but patients likely have already spread the disease by the time the diagnosis is made. Therefore, the emphasis should be on prevention through immunization to reduce the spread of pertussis.

4. Examples of preservation of self-integrity include all of the following except:

A. Using assistive equipment to move bariatric clients
B. Participating in wellness programs
C. Accepting the challenge of caring for clients with oppositional beliefs or practices
D. Using hand hygiene and personal protective equipment

Correct answer: C

Rationale: Preservation of self-integrity involves actions that support the nurse's well-being and ethical standards. Using assistive equipment to move bariatric clients and practicing hand hygiene and personal protective equipment are essential aspects of maintaining physical health and safety, contributing to self-care. Participating in wellness programs further enhances self-care by promoting overall well-being. However, accepting the challenge of caring for clients with oppositional beliefs or practices can be emotionally taxing and may compromise a nurse's self-integrity if it leads to significant moral distress or ethical conflicts. In such situations, it is important for nurses to prioritize their well-being and ethical values by seeking alternative solutions or support.

5. A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?

A. A statement explaining the condition the client was found in, quoting the client's words about the situation
B. An explanation of how the fall happened and when the physician was notified
C. An account of the conditions of the room that contributed to the client's fall
D. A summary of the client's medical history and current medications

Correct answer: A

Rationale: When a fall or injury occurs while under nursing care, it is crucial to document the known aspects of the situation and the response to the injury. In this scenario, the nurse should document the client's condition as found and quote the client's own words about the situation. This helps provide a clear account of the event without implying blame. Options B, C, and D are incorrect because detailing how the fall happened, listing room conditions, or summarizing medical history are not directly relevant to documenting the immediate situation and the client's own words following the fall.