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 client’s 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 client’s 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 client’s 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 doesn’t 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
PTS: 1
REF: Fluid and Electrolyte Balance
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
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 body’s 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