A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?

Edema

Oliguria

Hypotension

Hyperthemia

Answer and Explanation

The Correct Answer is A

A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.

B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.

C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.

D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature

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Correct Answer is A

Explanation

A) They must also take a vitamin D supplement: Calcium absorption is highly dependent on vitamin D, which facilitates the absorption of calcium in the intestines. Taking a vitamin D supplement alongside calcium ensures effective utilization of calcium, improving bone health and preventing deficiencies.

B) Reduce sodium intake: While reducing sodium intake can benefit overall health and reduce fluid retention, it is not directly related to the absorption of calcium supplements. The focus should be on ensuring adequate vitamin D levels for proper calcium absorption.

C) Decrease the amount of fiber in your diet: High fiber diets do not necessarily hinder calcium absorption to a significant extent. In fact, maintaining a balanced diet with adequate fiber is important for overall health. Fiber does not need to be reduced specifically for better calcium absorption.

D) Take the medication with orange juice to increase absorption: Orange juice is high in vitamin C, which does not significantly impact calcium absorption. Calcium supplements are best taken with vitamin D or with meals to enhance absorption, rather than with orange juice alone.

A. dysphagia B. hypoactive deep tendon reflexes (DTR) C. hypomagnesemia D. positive Chvostek sign hypertension

Correct Answer is C

Explanation

A) Dysphagia: While dysphagia (difficulty swallowing) can occur in individuals with long-term alcohol use, especially if there is coexisting neurological damage or esophageal disorders, it is not specifically associated with vomiting and diarrhea in the context of this scenario. The primary concern here involves electrolyte imbalances.

B) Hypoactive deep tendon reflexes (DTR): Hypoactive DTRs are typically associated with hypermagnesemia rather than hypomagnesemia. In this case, the client's condition is more likely to lead to electrolyte deficiencies, including hypomagnesemia, due to vomiting, diarrhea, and poor nutritional intake.

C) Hypomagnesemia: Chronic alcohol use often results in nutritional deficiencies, and vomiting and diarrhea can further exacerbate this by depleting electrolytes. Hypomagnesemia is a common finding in long-term alcoholics due to poor dietary intake, gastrointestinal losses, and renal losses. This can lead to symptoms such as muscle weakness, tremors, and altered mental status. Hypomagnesemia is particularly concerning because it can affect cardiovascular stability and neuromuscular function.

D) Positive Chvostek sign: A positive Chvostek sign is indicative of hypocalcemia, which can occur secondary to hypomagnesemia. However, it is not as directly associated with chronic alcoholism as hypomagnesemia itself. The positive Chvostek sign involves a facial muscle spasm in response to tapping the facial nerve and indicates neuromuscular irritability due to low calcium levels. While related, the primary electrolyte imbalance expected here is hypomagnesemia.

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