A nurse is assessing a client who is experiencing fluid volume excess. Which of the following findings should the nurse expect?

Poor skin turgor

Thready pulse

Crackles in lung bases

Flat neck veins

Answer and Explanation

The Correct Answer is C

Rationale

A. Poor skin turgor: Poor skin turgor is typically a sign of fluid volume deficit, not excess. In fluid overload, the skin may appear edematous or stretched rather than dehydrated. Assessing turgor helps differentiate between dehydration and overhydration.

B. Thready pulse: A thready, weak pulse is often associated with hypovolemia due to reduced circulating volume. In fluid volume excess, pulses are usually full and bounding because of increased intravascular pressure. Pulse quality provides insight into circulatory status.

C. Crackles in lung bases: Crackles heard in the lower lung fields indicate pulmonary fluid accumulation, a common finding in fluid volume excess. Excess intravascular fluid can leak into the alveoli, causing impaired gas exchange and respiratory symptoms. Auscultation of crackles helps identify pulmonary edema early.

D. Flat neck veins: Flat neck veins are associated with low central venous pressure, typically seen in dehydration or hypovolemia. In fluid overload, neck veins are often distended due to increased venous pressure. Jugular vein assessment is a key indicator of intravascular volume status.

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Correct Answer is C

Explanation

Rationale

A. A middle adult experiences physical changes: Physical changes such as menopause or decreased strength are normal developmental events and do not necessarily indicate a change in the family system. These are expected life transitions rather than stressor-induced changes in family roles.

B. A young adult develops a close, personal relationship: Forming intimate relationships is part of normal young adult development and does not, by itself, indicate a disruption or change in family dynamics. It is a typical milestone rather than a stressor affecting the family system.

C. A middle adult assumes their parent's responsibilities: Taking on parental responsibilities, such as caring for aging parents, reflects a significant role shift within the family system. This role reversal can create stress, alter family dynamics, and indicate a response to external or internal stressors affecting the family structure.

D. A young adult focuses on their career: Career development is a normal developmental task for young adults and does not inherently signal a change in family roles or system dynamics. It reflects personal growth and independence rather than stress-related change in family functioning.

A. "A client can be discharged to another facility if their behavior is unsafe and inappropriate." B. "A client can be discharged to another facility when their condition stabilizes." C. "A client can be discharged to another facility if they are unable to pay for services received." D. "A client can be discharged to another facility if their condition is terminal."

Correct Answer is B

Explanation

Rationale

A. "A client can be discharged to another facility if their behavior is unsafe and inappropriate.": EMTALA focuses on stabilizing medical emergencies, not on behavior-related issues. Discharging solely based on unsafe behavior would violate the client’s right to emergency care.

B. "A client can be discharged to another facility when their condition stabilizes.": EMTALA requires that clients presenting with an emergency medical condition must be evaluated and stabilized before discharge or transfer. This statement reflects proper understanding of the act’s requirement to ensure patient safety and continuity of care.

C. "A client can be discharged to another facility if they are unable to pay for services received.": EMTALA prohibits refusing care or transferring a patient based on inability to pay. Emergency treatment must be provided regardless of financial status, making this statement incorrect.

D. "A client can be discharged to another facility if their condition is terminal.": Terminal status alone does not justify discharge or transfer under EMTALA. The patient must still receive emergency stabilization or palliative support in compliance with legal and ethical requirements.

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A nurse is assessing a client who is experiencing fluid volume excess. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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