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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Diarrhea and vomiting for 36 hours:
Diarrhea and vomiting can lead to metabolic acidosis due to loss of bicarbonate and increased hydrogen ion concentration in the blood. However, the ABG values provided indicate respiratory alkalosis (high pH and low PaCO2), which is not consistent with metabolic acidosis caused by diarrhea and vomiting. Therefore, this choice does not correlate with the ABG values.
B. Chronic obstructive pulmonary disease (COPD):
COPD is a respiratory condition characterized by airflow limitation and increased airway resistance. It can lead to respiratory acidosis due to retention of carbon dioxide (PaCO2 levels would be elevated). The ABG values in the scenario show respiratory alkalosis (low PaCO2), which is the opposite of what would be expected in COPD. Therefore, this choice does not correlate with the ABG values provided.
C. Anxiety-induced hyperventilation:
Anxiety-induced hyperventilation is a common cause of respiratory alkalosis. During hyperventilation, there is excessive elimination of carbon dioxide (PaCO2 levels decrease), leading to an increase in pH (alkalosis). The ABG values in the scenario show a high pH (7.48) and low PaCO2 (28 mm Hg), consistent with respiratory alkalosis seen in hyperventilation due to anxiety.
D. Diabetic ketoacidosis and chronic obstructive pulmonary disease (COPD):
Diabetic ketoacidosis (DKA) is a metabolic condition characterized by hyperglycemia, ketosis, and metabolic acidosis (low pH and low bicarbonate levels). COPD, as mentioned earlier, can lead to respiratory acidosis due to retained carbon dioxide. Neither of these conditions correlates with the ABG values provided, which show respiratory alkalosis (high pH and low PaCO2). Therefore, this choice does not correlate with the ABG values.
Correct Answer is B
Explanation
A. Loose connective tissue:
Melanocytes are not typically found in loose connective tissue. Their primary location is within the epidermis, specifically in the basal layer, where they interact with keratinocytes to produce melanin and contribute to skin color. Loose connective tissue contains collagen and elastin fibers, as well as fibroblasts, but it does not house melanocytes.
B. Epidermis:
This is the correct answer. Melanocytes are primarily located in the basal layer of the epidermis, which is the deepest layer of the epidermis. These cells produce melanin, a pigment that helps protect the skin from UV radiation and determines skin color. Melanocytes are interspersed among keratinocytes in the epidermis and transfer melanin to keratinocytes to provide skin pigmentation.
C. Dermis:
The dermis is the layer of skin beneath the epidermis and consists of connective tissue, blood vessels, nerves, hair follicles, and sweat glands. While the dermis plays a crucial role in supporting and nourishing the epidermis, melanocytes are not primarily located in the dermis. They are confined to the basal layer of the epidermis.
D. Superficial fascia:
The superficial fascia, also known as the subcutaneous tissue or hypodermis, lies beneath the dermis and consists of adipose (fat) tissue and connective tissue. It provides insulation, energy storage, and cushioning for underlying structures. However, melanocytes are not typically found in the superficial fascia. They are restricted to the epidermis, specifically the basal layer, where they carry out their function of melanin production.
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