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

Not knowing what triggered the allergic reaction is a significant concern and may indicate a need for allergy testing and evaluation by an allergy specialist. Identifying the trigger allergen is crucial for implementing avoidance strategies, preventing future allergic reactions, and managing the client's overall health and well-being.
A. While the administration of epinephrine indicates the severity of the allergic reaction and the need for immediate treatment, it may not be the most important indication for referral to an allergy specialist on its own.
B. A biphasic reaction refers to the recurrence of symptoms after an initial resolution of an allergic reaction. Biphasic reactions can occur within hours or days after the initial reaction and can be severe or even life-threatening. This, however, does not necessitate need for a specialist.
C. While severe hypoglycemia can occur in some cases of anaphylaxis, it may not be the primary indication for referral to an allergy specialist.

A. The nurse sat at a slight angle across from the client. B. The nurse leaned away from the client throughout the interview. C. The nurse maintained an upright posture. D. The nurse maintained eye contact throughout the interview.

Correct Answer is B

Explanation

Leaning away from the client throughout the interview can convey a lack of interest or engagement in the conversation. It may appear as though the nurse is disinterested or uncomfortable, which could negatively impact the client's perception of the interaction.
A. Sitting at a slight angle across from the client is generally considered appropriate and allows for a comfortable and natural interaction
C. Maintaining an upright posture demonstrates attentiveness and professionalism during the interview.
D. Maintaining eye contact throughout the interview is generally considered a positive nonverbal behavior as it shows attentiveness, respect, and interest in the client's concerns.

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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 D

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Correct Answer is B

Explanation

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