A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

Thready pulse

Decreased bowel sounds

Bilateral muscle weakness

Distended neck veins

Answer and Explanation

The Correct Answer is D

A. Thready pulse:
A thready pulse is more indicative of fluid volume deficit or inadequate cardiac output, not fluid volume excess.
B. Decreased bowel sounds:
Decreased bowel sounds are not a specific sign of fluid volume excess. They may be associated with various gastrointestinal issues but are not directly related to fluid volume status.
C. Bilateral muscle weakness:
Bilateral muscle weakness is not a specific manifestation of fluid volume excess. It may be associated with electrolyte imbalances or other neuromuscular issues.
D. Distended neck veins:
This is the correct answer. Distended neck veins are a classic sign of fluid volume excess or overload. Increased venous pressure from excess fluid can lead to distension of the jugular veins in the neck. This finding is often seen in conditions such as heart failure or renal failure where there is an inability to adequately excrete or distribute fluids.

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Correct Answer is A

Explanation

A. Drowsiness:
This is the correct answer. Drowsiness or sedation is a common side effect of paroxetine, which is a selective serotonin reuptake inhibitor (SSRI). Clients should be informed about the potential for drowsiness, especially when initiating the medication or adjusting the dosage.
B. Tinnitus:
Tinnitus (ringing in the ears) is not a common side effect of paroxetine. It is important to monitor for auditory issues with medications, but paroxetine is not typically associated with tinnitus.
C. Peripheral edema:
Peripheral edema is not a common adverse effect of paroxetine. Swelling of the extremities is not typically associated with SSRIs like paroxetine.
D. Alopecia:
Alopecia (hair loss) is not commonly associated with paroxetine. Hair loss is not a typical side effect of SSRIs.

A. I take metformin for my diabetes. B. "I should avoid drinking grapefruit juice." C. I am trying to decrease my dietary fat intake" D. I was just diagnosed with hepatitis B

Correct Answer is D

Explanation

A. I take metformin for my diabetes:
This statement indicates that the client is aware of taking metformin for diabetes. It is relevant information but doesn't raise immediate concerns about the interaction with lovastatin.
B. "I should avoid drinking grapefruit juice:"
This is a correct statement. Grapefruit juice can interact with lovastatin, potentially increasing the risk of side effects. Advising the client to avoid grapefruit juice is a proper precaution when taking lovastatin.
C. I am trying to decrease my dietary fat intake:
This statement indicates a positive lifestyle change that aligns with the goal of using lovastatin to lower cholesterol. It is a positive and relevant statement.
D. "I was just diagnosed with hepatitis B:"
This is the correct answer. Lovastatin is metabolized by the liver, and liver function is an important consideration. The nurse should assess the severity of hepatitis B, the client's liver function, and whether lovastatin is contraindicated or requires dose adjustment based on the hepatic impairment.

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A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new prescription for paroxetine. The nurse should instruct the client to monitor for which of the following adverse effects?

Correct Answer is A

Explanation

A nurse is reviewing the plan of care with a client who has a new prescription for lovastatin. Which of the following statements by the client should indicate to the nurse a need for further assessment?

Correct Answer is D

Explanation

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