A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

Increased pulse rate

Decreased blood pressure

Skeletal muscle weakness

Warm and pink skin

Distended neck veins

Answer and Explanation

Correct Answer : E

A. Increased pulse rate:

This is a common manifestation of fluid overload. Excess fluid volume can lead to an increase in cardiac output, causing the heart to pump faster and resulting in an increased pulse rate.

B. Decreased blood pressure:

Fluid overload typically leads to increased blood volume, which can initially cause an increase in blood pressure. However, as fluid overload progresses, it can lead to fluid redistribution, venous congestion, and decreased systemic vascular resistance, ultimately resulting in decreased blood pressure.

C. Skeletal muscle weakness:

Skeletal muscle weakness is not a direct manifestation of fluid overload. It is more commonly associated with electrolyte imbalances, such as hypokalemia or hypomagnesemia, which can occur as a consequence of fluid shifts but are not specific to fluid overload itself.

D. Warm and pink skin:

Warm and pink skin is not typically associated with fluid overload. Instead, it is more indicative of adequate tissue perfusion and oxygenation. In fluid overload, skin changes may include edema, cool and clammy skin due to venous congestion, or signs of skin breakdown in areas of pressure.

E. Distended neck veins:

Distended neck veins, specifically jugular venous distention (JVD), are commonly seen in patients with fluid overload, especially if there is right-sided heart failure or increased central venous pressure. JVD is a result of increased venous return to the heart due to fluid accumulation.

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Correct Answer is ["A","D","E"]

Explanation

A. Decreased plasma volume:Burn injuries cause a significant inflammatory response, leading to fluid shifts from the intravascular space to the interstitial space. This results in hypovolemia and decreased plasma volume, especially during the acute phase of burns.

B. Diuresis:Diuresis typically occurs after fluid resuscitation and stabilization of the client (in the later phase of burn recovery). In the initial phase, oliguria is more common due to hypovolemia and reduced renal perfusion.

C. Hypermagnesemia:Hypermagnesemia is not typically associated with burn injuries. Instead, clients with burns often experience hypomagnesemia due to fluid shifts, protein loss, and increased renal losses.

D. Capillary leak:Burn injuries lead to a systemic inflammatory response, causing capillary leak syndrome. This increases vascular permeability, allowing fluid, electrolytes, and proteins to leak into the interstitial spaces, contributing to edema and hypovolemia.

E. Loss of protein:Proteins are lost through damaged capillaries and open burn wounds, contributing to decreased oncotic pressure, edema, and a need for aggressive nutritional support to promote healing and recovery.

A. Superficial infections are caused by fungus. B. Parasites get underneath the skin. C. Hair follicles are infected or inflamed. D. There is an allergic response to an allergen.

Correct Answer is C

Explanation

A. Superficial infections are caused by fungus.

While fungal infections can indeed cause superficial skin infections like tinea (ringworm) or candidiasis, they are not the common factor for the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions primarily involve bacterial infections of the hair follicles, typically caused by Staphylococcus aureus bacteria.

B. Parasites get underneath the skin.

Parasitic infections can cause various skin conditions, but they are not the common factor for folliculitis, furuncles, and carbuncles. These conditions are specifically related to bacterial infections of the hair follicles rather than parasitic infestations.

C. Hair follicles are infected or inflamed.

This is the correct choice and the common factor for folliculitis, furuncles, and carbuncles. All three conditions involve the infection or inflammation of hair follicles, primarily due to Staphylococcus aureus bacteria. Folliculitis is the inflammation of one or more hair follicles, furuncles are deeper infections involving the hair follicle and surrounding tissue, and carbuncles are clusters of interconnected furuncles with deeper tissue involvement.

D. There is an allergic response to an allergen.

An allergic response to an allergen does not play a role in the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions are primarily infectious in nature, involving bacterial colonization and subsequent inflammation of the hair follicles rather than an allergic response.

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A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

What is the common factor for etiology and pathophysiology of folliculitis, furuncles, and carbuncles?

Correct Answer is C

Explanation

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