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
Dairy products contain lactose, and individuals with lactose intolerance often experience gastrointestinal symptoms such as bloating, gas, and diarrhea after consuming dairy. Advising the client to decrease dairy products in their diet can help alleviate these symptoms and manage lactose intolerance effectively.
A, C, D do not directly relate to lactose intolerance.
Correct Answer is B
Explanation
Sitting with the client during meals and snacks provides support, encouragement, and supervision to ensure that the client is consuming an adequate amount of food. It also offers an opportunity for the nurse to monitor the client's eating habits, aid if needed.
A. Enrolling the client in a nutritional class may not be the most appropriate action in this situation.
C. While monitoring the client's weight is important for assessing nutritional status and detecting changes over time, weighing the client at the same time every morning may not directly address the underlying issues contributing to malnutrition.
D. While spiritual and emotional support can be beneficial for clients with major depressive disorder, arranging a consultation with the facility chaplain may not directly address the client's nutritional needs or contribute to improving their nutritional status.
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