A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?
Dark-colored urine
High blood pressure
Distended neck veins
Moist skin
The Correct Answer is A
A. Dark-colored urine is a common finding in dehydration, indicating concentrated urine.
B. Dehydration is more likely to be associated with hypotension rather than high blood pressure.
C. Distended neck veins are more associated with fluid overload, not dehydration.
D. Moist skin is not a typical finding in dehydration; dry skin is more common.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Diarrhea can lead to significant fluid loss, causing dehydration.
B. Hypothermia is not a typical finding associated with diarrhea; instead, clients may experience fever or an elevated body temperature.
C. Diarrhea is more likely to be associated with increased bowel sounds rather than decreased bowel sounds.
D. A rigid abdomen is not a common finding in diarrhea; it may suggest more serious conditions such as peritonitis.
Correct Answer is C
Explanation
- A) Concept mapping is a tool that helps in organizing and representing knowledge. It can aid in the understanding of relationships between different concepts but is not a decision-making component in itself.
- B) Clinical reasoning is the process used by practitioners to collect cues, process the information, come to an understanding of a patient situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process. It is part of the broader decision-making process.
- C) Clinical judgement is the conclusion or enlightened opinion at which a nurse arrives following a process of observation, reflection, and analysis of observable or available information or data. It is essential for making evidence-based decisions in clinical practice.
- D) Critical thinking is the objective analysis and evaluation of an issue in order to form a judgement. It is an important skill in the decision-making process but is not a component of the decision itself.
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