A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following indicates fluid volume deficit?
Decreased hematocrit
Decreased specific gravity of urine
Increased skin turgor
Increased pulse rate
The Correct Answer is D
A. Decreased hematocrit may be seen in fluid volume excess, not deficit.
B. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit.
C. Increased skin turgor is a clinical manifestation of fluid volume deficit.
D. Increased pulse rate is a compensatory response to fluid volume deficit, reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Granulex is a topical medication used for wound care, but it may not be the first choice for a stage II pressure ulcer.
B. Hydrocolloid dressings are appropriate for stage II pressure ulcers, providing a moist environment to support healing and protecting the wound from contamination.
C. Proteolytic enzymes are used for debridement of necrotic tissue and may not be the primary choice for a stage II pressure ulcer.
D. Cortisone cream is a topical steroid that may be used for certain skin conditions but is not typically the first-line treatment for pressure ulcers.
Correct Answer is A
Explanation
A. The client's belief that his needs will be met through education reflects intrinsic motivation, which is likely to enhance the client's commitment to learning and self-care.
B. Seeking family approval may be a motivator, but it is an external factor, and intrinsic motivation is generally more effective for sustained behavior change.
C. While the nurse explaining the need for education is important, the client's personal belief and understanding of the value of education are key for motivation.
D. The nurse's empathy is essential for building rapport, but the client's belief in the benefits of education is more directly related to motivation.
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