A nurse in the emergency department is caring for a client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
The client reports symptoms of vomiting and diarrhea for the past 12 hours. These symptoms are classic indicators of fluid loss from the gastrointestinal tract. Vomiting and diarrhea lead to significant fluid depletion, resulting in a fluid volume deficit. This deficit can lead to dehydration, electrolyte imbalances, and potentially hypotension (low blood pressure), which are consistent with the client's clinical presentation of tachycardia (increased heart rate) and hypotension (blood pressure 102/58 mmHg). The plan for IV fluid replacement upon admission reflects the need to address and correct this fluid deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Immunosuppressant medications are drugs that suppress or weaken the immune system. They are often prescribed to prevent rejection of transplanted organs or to treat autoimmune diseases. However, a weakened immune system makes individuals more susceptible to infections because their body's ability to fight off pathogens is compromised. Therefore, clients taking immunosuppressant medications have an increased risk of contracting communicable diseases.
B. Poor nutrition can weaken the immune system, making it less effective in defending against infections. Essential nutrients such as vitamins and minerals play crucial roles in immune function. A deficiency in these nutrients can impair immune responses, making individuals more vulnerable to communicable diseases.
C. Keeping immunizations up to date helps protect individuals from specific communicable diseases for which vaccines are available. Vaccines stimulate the immune system to produce antibodies against particular pathogens, providing immunity. Therefore, if immunizations are up to date, the client's risk of contracting certain communicable diseases is reduced.
D. Aging is associated with changes in the immune system, known as immunosenescence, which can weaken immune responses. Older adults may have decreased production of immune cells and antibodies, making them more susceptible to infections. Additionally, aging is often accompanied by chronic health conditions or medications that further compromise immune function, increasing the risk of communicable diseases.
E. Living in a nursing home or long-term care facility can increase the risk of exposure to communicable diseases due to close contact with other residents, sharing of common spaces, and potentially inadequate infection control practices. Older adults in nursing homes may also have multiple chronic conditions and weakened immune systems, further increasing their susceptibility to infections.
Correct Answer is A
Explanation
A. Calling the healthcare provider is a reasonable action, especially when there is a significant change in the patient's condition, such as weight gain and generalized edema. The nurse may need further guidance on adjusting medications or additional interventions.
B. Diuretics are commonly prescribed for patients with heart failure to manage fluid overload. If the patient has not been compliant with taking their diuretic as prescribed, it could contribute to fluid retention and exacerbation of symptoms. Therefore, ensuring medication adherence is important. However, this alone may not address the acute issue of current weight gain and edema.
C. Daily weight monitoring is crucial for patients with heart failure as it can indicate fluid retention early on. Reinforcing the importance of daily weights helps in early detection of changes and facilitates timely intervention. However, in this scenario, the nurse has already noted a significant weight gain and edema since the last visit, so immediate action beyond education is needed.
D. Documenting the findings is essential for maintaining accurate patient records. However, in the context of a patient with heart failure who has shown signs of worsening (weight gain and edema), immediate action to address the worsening condition is necessary.
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