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 D

Explanation

Identifying the client's primary health issue or reason for seeking care, the nurse can prioritize the assessment and subsequent care interventions accordingly. This approach ensures that urgent or important health issues are addressed promptly, contributing to patient safety and satisfaction.

A. Initiate a liquid diet for the client. B. Place the client in a lateral position. C. Arrange the food groups clockwise on the client's plate. D. Provide an adaptive feeding device for the client.

Correct Answer is D

Explanation

Adaptive feeding devices are specifically designed to assist individuals with limited hand movement in feeding themselves more independently. These devices can include utensils with larger handles, specialized grips, or devices that stabilize food items for easier manipulation. Providing such devices can enhance the client's ability to feed themselves and promote autonomy in their daily activities.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the intake health assessment at a clinic. Which of the following is the priority action for the nurse to take?

Correct Answer is D

Explanation

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

Correct Answer is D

Explanation

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