Question 1

A client with an elevated body temperature and excessive sweating is prescribed intake and output measurements. What should the nurse include when making these measurements? (Select all that apply.)

Accepted Answer

A)   Sensible water loss
B)   Insensible water loss
C)   Indeterminate water loss
D)   Indiscriminate water loss
E)   Uncompensated water loss A,B

Question 2

An adolescent student visits the school nurse because of feeling nervous and shaky after drinking several cups of coffee and caffeinated soda throughout the day. Which statement should the nurse make to this student?

Accepted Answer

A)   "Many adults drink more caffeine that that in a day."
B)   "Caffeine is a central nervous depressant and can cause you to feel funny."
C)   "Caffeine is a form of drug and can cause serious health problems if overused."
D)   "You are probably not feeling well because you did not eat breakfast and have low blood sugar." C

Question 3

A critically ill younger client has an elevated serum sodium level. Which action should the nurse take after learning of this laboratory value?

Accepted Answer

A)   Evaluate for edema
B)   Assess for skin tenting
C)   Check body temperature
D)   Obtain a pulse oximeter measurement B

Question 4

The nurse prepares an educational pamphlet on caffeine for a community health fair. Which statements should the nurse include in this material? (Select all that apply.)

Accepted Answer

A)   Caffeine increases gastric acid
B)   Caffeine can cause toxic side effects in large doses
C)   Soda contains more caffeine than either coffee or tea
D)   The amount of caffeine found in coffee and tea varies by brand
E)   Women and adolescents consume the most caffeine in the United States

Question 5

A pregnant adolescent is not gaining weight and reports having a few beers with friends over the weekends. Which response should the nurse make to this client? (Select all that apply.)

Accepted Answer

A)   "This just shows what kind of a mother you will be."
B)   "No amount of alcohol has been proven safe to consume during pregnancy."
C)   "An occasional beer may be safe, but why take a chance with your baby's health?"
D)   "Alcohol use during pregnancy is toxic to the fetus and can affect normal development."
E)   "Alcohol can prevent the absorption of nutrients that are important for fetal development."

Question 6

A client who drinks 3 to 4 martinis before dinner every night feels that people who drink beer are alcoholics because of the volume of alcohol in each can. Which response should the nurse make to this client?

Accepted Answer

A)   "Beer and martinis have the same alcohol and calorie content."
B)   "Only beer drinkers are considered alcoholics if they overindulge."
C)   "The alcohol in 4 martinis is equal to about 11 cans of regular beer."
D)   "People who drink martinis may consume a smaller amount of alcohol but can still be considered alcoholics."

Question 7

The nurse notes that several students experience muscle weakness, dizziness, and increased heart rate after cross-country practice. Which action should the nurse take? (Select all that apply.)

Accepted Answer

A)   Attend all sports events to ensure students are adequately hydrated
B)   Discuss the need for athletes to have extra fluids with the physical education staff
C)   Coordinate emergency personnel to be present during every cross-country practice
D)   Arrange a special class for athletes to discuss good hydration and symptoms of dehydration
E)   Include information about the symptoms and effects of altered fluid status in health class which is mandatory for all students

Question 8

The nurse prepares to care for a group of assigned clients. Which body substance should the nurse recall that helps maintain an even core body temperature?

Accepted Answer

A)   Fat
B)   Skin
C)   Water
D)   Muscle

Question 9

A client with poorly controlled hypertension has a blood pressure of 190/96 mm Hg. Which food item should the nurse identify that may have contributed to this elevated measurement?

Accepted Answer

A)   Coffee
B)   Banana
C)   Oat meal
D)   Scrambled eggs

Question 10

An older client is experiencing dizziness when moving from a sitting to a standing position. Which findings should indicate to the nurse that this client may be dehydrated? (Select all that apply.)

Accepted Answer

A)   Slightly confused
B)   Increased heart rate
C)   Lower extremity edema
D)   Blood pressure lower than usual
E)   Weight loss of 8 pounds since last month

Question 11

A male client has stopped smoking, plays golf twice a week, and drinks two glasses of wine a night because of learning it is good for the heart. Which response should the nurse make to this client?

Accepted Answer

A)   "Any amount of alcohol is bad for your health."
B)   "Wine is low in calories so should not cause weight gain."
C)   "Wine has definitely been linked with liver cancer and should be avoided."
D)   "Two glasses of wine would be considered drinking in moderation, but any more could cause problems such as hypertension or liver disease."

Question 12

The nurse assesses an older client with altered cognition. Which finding indicates to the nurse the client has an alteration in fluid balance? (Select all that apply.)

Accepted Answer

A)   Dry oral mucosa
B)   Dark colored urine
C)   Increased heart rate
D)   Lower extremity edema
E)   Increased respiratory rate

Question 13

A client who is pregnant with a first child asks if alcohol can be consumed while pregnant. Which response should the nurse make to this client?

Accepted Answer

A)   "If having wine with dinner is usually done, you should drink it."
B)   "Consider drinking beer instead because it contains more nutrients."
C)   "To keep your baby as safe as possible, alcohol should be avoided during pregnancy."
D)   "One or two glasses of wine with dinner should not be harmful, but avoid liquor and beer."

Question 14

A client is experiencing confusion, rapid heart rate, and an elevated body temperature. For which health problem should the nurse plan care for this client?

Accepted Answer

A)   Fever
B)   Viral infection
C)   Altered fluid status
D)   Increased heart rate

Question 15

The nurse is concerned about a critically ill client's fluid intake because intravenous fluids have expired. For which role of water in the human body should the nurse be most concerned in this client?

Accepted Answer

A)   Euhydration
B)   Weight stabilization
C)   Elimination of fecal material
D)   Transport of nutrients and other substances

Question 16

A client who experiences fatigue, elevated temperature, and confusion after running a marathon has a urine specific gravity of 1.039. What should the nurse suspect be occurring with this client?

Accepted Answer

A)   Euhydration
B)   Dehydration
C)   Water toxicity
D)   Overhydration

Question 17

A client with Alzheimer disease in an assisted living complex has been treated for dehydration because of not drinking fluid unless it is offered. Which approach should the nurse use to monitor this client's hydration status?

Accepted Answer

A)   Monitor weight daily
B)   Monitor input and output
C)   Offer coffee several times a day
D)   Provide a pitcher of water and track how much is consumed.

Exam 8: Fluid, Caffeine, and Alcohol