Exam Cram NCLEX RN Practice Questions - Nurselytic

Correct Answer: C

Rationale: Unexplained weight loss in a patient with pneumonia could indicate an underlying short-term illness or a chronic condition like endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension is not commonly associated with weight loss; it usually leads to weight gain due to fluid retention. Unhealthy eating habits are less likely to explain significant unexplained weight loss over a short period. Mental health dysfunctions can affect appetite but are not typically primary causes of significant unexplained weight loss.

Correct Answer: B

Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss.
Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.

Correct Answer: C

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important.
Choice A is incorrect as providing a vague reassurance does not address the patient's query.
Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect.
Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.

Correct Answer: A

Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2°C.
Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child.
Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used.
Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.

Correct Answer: A

Rationale: You should convert the number of ounces into cc because cc is the unit of measurement used to record intake and output accurately. This urinary output falls within normal limits, so there is no need to report it immediately to the nurse. It is essential to report urinary outputs of less than 30 cc per hour to detect potential issues early. Converting ounces into centimeters (cm) is not appropriate in this context as cm is a unit of length, not volume. Knowing that 25 ounces of urine is too much in 8 hours is inaccurate as it depends on various factors like fluid intake and individual differences.