A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect?
Epistaxis.
Headache.
Dizziness.
Shortness of breath.
The Correct Answer is C
Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss. Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.
Choice A is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.
Choice B is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.
Choice D is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.
Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults. Normal ranges for heart rate are 60 to 100 beats per minute for adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
. Taking a hot shower in the morning can help decrease stiffness and improve joint mobility for people with rheumatoid arthritis. This is one of the self-management strategies that can reduce pain and disability.
Choice A is wrong because applying cold packs directly on the skin of the affected joints can cause vasoconstriction and increase inflammation.
Cold therapy should be used with caution and with a barrier between the skin and the ice pack.
Choice B is wrong because biological response modifiers are not used to prevent infection, but to reduce inflammation and slow down joint damage in rheumatoid arthritis.
These medications can actually increase the risk of infection by suppressing the immune system.
Choice D is wrong because clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis.
It is better to pace activities throughout the day and take frequent breaks to rest the joints.
Normal ranges for rheumatoid arthritis are based on the disease activity score (DAS), which measures the number of swollen and tender joints, the level of inflammation in the blood, and the patient’s global assessment of health. A DAS below 2.6 indicates remission, a DAS between 2.6 and 3.2 indicates low disease activity, a DAS between 3.2 and 5.1 indicates moderate disease activity, and a DAS above 5.1 indicates high disease activity.
Correct Answer is B
Explanation
The correct answer is choice b. Remove the device from the room.
Choice A rationale:
Reporting the defect to the equipment maintenance staff is important, but the immediate priority is to ensure the client’s safety by removing the faulty device.
Choice B rationale:
Removing the device from the room is the first action to take to prevent any potential electrical hazards or injuries to the client.
Choice C rationale:
Initiating a requisition for a replacement CPM device is necessary but should be done after the faulty device has been removed to ensure safety.
Choice D rationale:
Ensuring the device inspection sticker is current is part of routine checks, but it does not address the immediate safety concern posed by the frayed cord.
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