A client who is under extreme stress will have an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse should expect a decrease in which clinical finding?
Serum osmolarity
Urinary output
Insensible fluid loss
Blood pressure
The Correct Answer is B
When a client experiences increased production of antidiuretic hormone (ADH) and aldosterone due to extreme stress, the body's response is aimed at retaining fluid to maintain blood pressure and hydration. As a result, urinary output decreases because the kidneys retain more water, leading to concentrated urine production. This decrease in urinary output helps conserve fluids and contributes to maintaining blood pressure and hydration levels in response to stress.
A. Serum osmolarity: With increased ADH production, serum osmolarity tends to remain stable or may even increase slightly due to the retention of water. ADH acts on the kidneys to increase water reabsorption, which can concentrate the blood and elevate serum osmolarity.
B. Urinary output: Increased production of ADH and aldosterone leads to decreased urinary output as the kidneys retain more water. This response helps conserve fluid volume and maintain hydration during times of stress.
C. Insensible fluid loss: Insensible fluid loss, which includes water lost through respiration and skin evaporation, is not directly affected by ADH and aldosterone. These hormones primarily influence renal water retention rather than insensible fluid loss.
D. Blood pressure: Although aldosterone can indirectly affect blood pressure by increasing sodium retention and therefore influencing fluid balance, its primary role is to regulate sodium and potassium levels. Blood pressure may be influenced by various factors, including stress, hydration status, and cardiovascular health, but it is not directly decreased as a result of increased ADH and aldosterone production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Type of diet: While the type of diet may be relevant to the overall health and well-being of the older adult client, it may not directly contribute to understanding the change in mental status. While nutritional deficiencies or imbalances could potentially impact mental status, other factors are more immediately relevant to assessing the change in mental status.
B. Cultural considerations: Cultural considerations are important in providing holistic care to the older adult client, but they may not directly contribute to understanding the change in mental status. Cultural factors could influence communication styles, beliefs about health and illness, and preferences for care, but they may not be the primary focus when assessing a change in mental status.
C. Gender: Gender may have some relevance to the overall health and well-being of the older adult client, but it may not directly contribute to understanding the change in mental status. While certain gender-related factors, such as hormonal changes or gender-specific health conditions, could potentially impact mental health, they may not be the primary focus when assessing a change in mental status.
D. History of onset: This represents a critical thinking approach because understanding the history of onset of the change in mental status is essential for identifying potential causes and determining appropriate interventions. The timing and circumstances surrounding the onset of the change can provide valuable information about possible contributing factors, such as recent illnesses, medication changes, trauma, or environmental changes. By gathering information about the history of onset, the nurse can engage in critical thinking to formulate hypotheses, prioritize assessments, and develop a plan of care tailored to the client's needs.
Correct Answer is B
Explanation
A. Temperature: While temperature assessment is important in evaluating a client's condition, it primarily indicates the presence of fever, which the client already reports. However, it does not provide direct information about the client's fluid status.
B. BP and pulse in lying, then sitting and standing positions: Assessing blood pressure (BP) and pulse in different positions (lying, sitting, and standing) helps evaluate orthostatic changes, which can indicate volume depletion or dehydration. A drop in BP and an increase in pulse rate upon standing suggest volume depletion and orthostatic hypotension, which are indicators of fluid loss.
C. Pulse oximetry reading on room air: Pulse oximetry measures the oxygen saturation of arterial blood and is primarily used to assess respiratory status and oxygenation. While it provides valuable information about oxygen levels, it does not directly assess fluid status.
D. Respiratory rate and depth: Respiratory rate and depth can be affected by various factors, including pain, fever, and respiratory conditions. While changes in respiratory rate and depth can indicate distress or respiratory compromise, they are not specific indicators of fluid status and may not directly reflect hydration status.
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