A client with cirrhosis and severe ascites is scheduled for a paracentesis. Post-procedure, the client develops signs of tachycardia, hypotension, and mild fever.
Which conditions could cause these symptoms? Select all that apply.
Fluid overload.
Cardiac decompensation.
Hypovolemia.
Paracentesis-induced peritonitis.
Anxiety.
Correct Answer : C,D
Post-paracentesis complications require understanding fluid dynamics and infection risks. Rapid removal of ascitic fluid can cause massive fluid shifts, leading to circulatory collapse. Knowledge of sterile technique and hemodynamics is essential to differentiate between hypovolemia and peritonitis following the procedure.
Choice A rationale
Fluid overload would typically manifest as hypertension, neck vein distention, and crackles in the lungs. Tachycardia and hypotension are classic signs of volume depletion rather than an excess of fluid within the intravascular space following paracentesis.
Choice B rationale
While cardiac issues can cause hypotension, the specific context of post-paracentesis points toward volume shifts. Cardiac decompensation often involves fluid backup and pulmonary congestion, which does not align with the sudden loss of high volume peritoneal fluid.
Choice C rationale
Rapid removal of large volumes of ascitic fluid (often > 5 liters) causes shift from the intravascular space to the interstitium. This leads to decreased circulating volume, manifesting as tachycardia and hypotension (systolic < 90 mm Hg).
Choice D rationale
Peritonitis is a risk when the peritoneal cavity is punctured. Clinical signs include fever (normal range 36.5 to 37.5 degrees Celsius), abdominal pain, and tachycardia. Fever in this client suggests a potential inflammatory or infectious process.
Choice E rationale
Anxiety can cause tachycardia, but it rarely causes significant hypotension and fever. The nurse must prioritize physiological causes like fluid shifts or infection over psychological distress when vital signs are significantly altered after an invasive procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Accurate neurologic assessment in suspected stroke requires systematic comparison to identify focal deficits. Applying knowledge of neuroanatomy and lateralization of brain function is essential to differentiate between localized ischemic events and generalized systemic issues, ensuring the correct vascular territory is identified.
Choice A rationale
Rapid assessments may lead to overlooking subtle focal neurologic deficits or sensory changes. Precision is required to localize the brain lesion accurately. While time is critical in stroke, haste must not compromise the integrity and detail of the examination.
Choice B rationale
The supine position may increase intracranial pressure or compromise the airway in a stroke patient with decreased gag reflexes. Assessing certain reflexes and motor strength often requires varying the head of the bed to at least 30 degrees for safety.
Choice C rationale
Symmetry is the hallmark of neurologic health. Comparing left and right sides allows the nurse to identify unilateral weakness, sensory loss, or reflex changes characteristic of stroke. This lateralization helps distinguish focal neurological deficits from global brain dysfunction.
Choice D rationale
Anxiolytics can depress the central nervous system, altering the level of consciousness and pupillary responses. This medication masks the client's true neurologic status, making it impossible to obtain a baseline or detect subtle clinical changes or deterioration.
Correct Answer is A
Explanation
Caring for clients with traumatic brain injury requires understanding cranial nerve function and the mechanics of swallowing. Knowledge of the multidisciplinary approach to dysphagia is necessary to prioritize interventions that ensure airway protection and prevent complications like aspiration pneumonia.
Choice A rationale
A speech-language pathologist is the specialized professional trained to perform a comprehensive bedside swallow evaluation or videofluoroscopic study. Identifying the specific phase of dysphagia is the essential first step before implementing any feeding or thickening.
Choice B rationale
Oral care is important for hygiene and reducing bacterial load in the mouth, which can decrease the risk of pneumonia if aspiration occurs. However, it does not identify the underlying physiological cause of the swallowing impairment.
Choice C rationale
Elevating the head of the bed to 90 degrees during meals is a standard safety intervention to prevent aspiration. While helpful, it should follow a professional assessment to determine if the client is safe to swallow.
Choice D rationale
Providing modified diets is a common intervention for dysphagia. However, the nurse should not independently determine the consistency of food or liquids without a formal recommendation from an expert following a diagnostic assessment..
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