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

Answer and Explanation

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.

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Correct Answer is A

Explanation

This is important because it allows the nurse to assess the client's ability to communicate in their primary language. Knowing the client's level of fluency helps the nurse determine the most effective communication strategies and whether an interpreter is necessary.

B. While nodding can be a form of nonverbal communication indicating understanding, relying solely on this may not accurately gauge the client's comprehension.

C. Even in the presence of n interpreter, the nurse should speak directly to the client.

D. Family members may not be proficient in both languages or may not accurately convey medical information.

A. Client's hearing deficit B. Volume of the client's television C. Numerous visitors in the client's room D. Increase in pain after ambulation E. Adverse effects of opioid analgesic F. Using earphones while listening to music

Correct Answer is ["A","C","D","E","F"]

Explanation

The client's hearing deficit can certainly present a barrier to effective communication, as it may affect their ability to hear and understand verbal instructions or information provided by the nurse.
B. The loud volume of the client's television is not a barrier in this case as the client has hearing loss.
C. Having numerous visitors in the client's room can create distractions and make it challenging for the nurse to engage in private, focused communication with the client.
D. An increase in pain after ambulation can impact the client's ability to focus and engage in effective communication. The client may be preoccupied with managing their pain, which can hinder their receptiveness to communication from the nurse.
E. Adverse effects of opioid analgesic: Adverse effects of opioid analgesics, such as drowsiness or sedation, can impair the client's cognitive function and alertness, making it difficult for them to participate actively in communication with the nurse.
F. Using earphones while listening to music may create a physical barrier to communication, as it limits the nurse's ability to speak directly to the client or gain their attention.

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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.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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