Exam Cram NCLEX RN Practice Questions - Nurselytic

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: D

Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect.
Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.

Correct Answer: C

Rationale: Acromegaly is a condition characterized by excessive secretion of growth hormone in adulthood after normal body growth completion. This hormonal excess leads to overgrowth of bones in the face, head, hands, and feet; however, there is no significant change in height. Stating sternal deformity and hyperextensible joints is incorrect as they are characteristic findings of Marfan syndrome. Growth retardation and delayed onset of puberty are not typical of acromegaly but are seen in hypopituitary dwarfism. Increased height, weight, and delayed sexual development are features of gigantism, not acromegaly.
Therefore, the correct assessment finding in a patient with acromegaly would be overgrowth of bone in the face, head, hands, and feet.

Correct Answer: A

Rationale:
To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse.
Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

Correct Answer: B

Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of ³20 mm Hg or ³10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension.

Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.