A nurse in a critical care unit is assessing an adult client. Which of the following findings by the nurse indicates a fluid volume deficit?

Heart rate 118/min

Central venous pressure 25 mm Hg

Blood pressure 152/90 mm Hg

Temperature 37.2° C (99° F)

Answer and Explanation

The Correct Answer is A

A.   A heart rate of 118/min suggests tachycardia, which is a compensatory mechanism in response to fluid volume deficit. The body increases heart rate to maintain cardiac output when fluid volume is low.
B.   A central venous pressure of 25 mm Hg may indicate fluid volume overload rather than deficit. It suggests increased venous pressure, possibly due to excess fluid.
C.   A blood pressure of 152/90 mm Hg is within the normal range and does not specifically indicate fluid volume deficit.
D.   A temperature of 37.2°C (99°F) is within the normal range and does not specifically indicate fluid volume deficit.

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Correct Answer is D

Explanation

A. Having someone remain with the client for 30 minutes after meals can provide support and encouragement to prevent purging behaviorwhich are common with bulimia andnot anorexia nervosa.
B. Offering a selection of beverages at each meal may not directly address the underlying issues associated with anorexia nervosa.

C. Informing the client of a specific weight gain expectation may increase anxiety and may not be appropriate given the individualized nature of weight restoration in anorexia nervosa
treatment.

D. Encouraging the client to participate in developing dietary goals is important for fostering autonomy and empowerment and is associated with better compliance.

A. “A low-protein diet should be followed for 3 months prior to conception." B. "Breastfeeding will prevent your baby from developing PKU." C. "Serum bilirubin should be monitored one to two times per month during pregnancy." D. "Diet sodas should not be consumed more than two or three times per week."

Correct Answer is A

Explanation

A. For individuals with PKU who are planning a pregnancy, it is recommended to follow a low- protein diet prior to conception to minimize the risk of maternal phenylalanine levels causing harm to the developing fetus.

B. Breastfeeding does not prevent a baby from developing PKU. Babies born to mothers with PKU need special formula to avoid the harmful effects of high levels of phenylalanine in breast milk.
C. Monitoring serum bilirubin levels is not specific to PKU management during pregnancy.

D. Consumption of diet sodas is not directly related to PKU management during pregnancy.

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A nurse in a critical care unit is assessing an adult client. Which of the following findings by the nurse indicates a fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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