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 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.

A. The client explains they are not planning to leave their home. B. The client thinks their home will be safer now that there is a baby in the house C. The client thanks the nurse for the information. D. The client puts the number of the crisis center into their phone.

Correct Answer is D

Explanation

It indicates that the client acknowledges the importance of having a safety plan and is willing to take proactive measures to ensure their well-being and that of their child. This response suggests a positive engagement with the safety plan provided by the nurse.
A. This response indicates that the client may not perceive their current situation as unsafe or may not be ready to take action to address potential safety concerns.
B. This response suggests that the client may have misconceptions about how the presence of a baby in the home affects safety, especially in the context of intimate partner violence.
C. While expressing gratitude for the information provided is a positive response, it does not necessarily indicate whether the client understands the seriousness of the situation or plans to utilize the resources provided.

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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

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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