A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)
Pale yellow urine
Bradycardia
Poor skin turgor
Flat neck veins
Hypotension
Correct Answer : C,D,E
A. In cases of dehydration, urine output may decrease, resulting in a more concentrated urine that appears darker in color. Therefore, the nurse may expect the urine to be darker in color.
B. Tachycardia is more commonly observed due to dehydration and the body's compensatory mechanisms.
C. Poor skin turgor is a classic sign of dehydration and may be observed in clients with vomiting and diarrhea.
D. Flat neck veins are typically associated with dehydration. This occurs due to reduced intravascular volume leading to collapse of the veins.
E. Hypotension is commonly associated with dehydration resulting from vomiting and diarrhea. Loss of fluids and electrolytes can lead to decreased blood volume and subsequent hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Providing toys or drawing materials can help the child express their thoughts, feelings, and experiences in a nonverbal and developmentally appropriate manner. Play-based activities allow children to communicate and process their emotions more comfortably than verbal communication alone.
For young children, especially those who have experienced trauma, the presence of a caregiver can provide comfort, reassurance, and support during the assessment process.
C. Neglecting the child's emotional needs can result in overlooking important aspects of their experience and hinder their recovery.
D. Asking the child to repeat the events of the trauma can be retraumatizing and overwhelming for them. It may increase their distress and hinder their ability to cope with the experience.
Correct Answer is ["B","C"]
Explanation
This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.
B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.
C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.
D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.
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