A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?
Pyuria
Weight loss
Jugular vein distention
Muscle contractions
The Correct Answer is C
Choice A reason: Pyuria, or pus in the urine, is not a direct sign of fluid volume overload. It may indicate a urinary tract infection, kidney stones, or other renal problems.
Choice B reason: Weight loss is not a typical finding of fluid volume overload. In fact, weight gain is a common symptom of fluid retention, as the body holds more fluid than it excretes.
Choice C reason: Jugular vein distention, or the bulging of the neck veins, is a serious indicator of fluid volume overload. It reflects increased pressure in the right side of the heart and the systemic circulation. It may also signal heart failure, pulmonary hypertension, or pericardial tamponade.
Choice D reason: Muscle contractions are not directly related to fluid volume overload. They may be caused by electrolyte imbalances, dehydration, muscle fatigue, or nerve disorders.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Drinking a minimum of 12 ounces of fluid with each meal is not recommended for a client who has dumping syndrome. Fluids can increase the gastric volume and accelerate the gastric emptying, leading to more severe symptoms. The nurse should advise the client to drink fluids between meals, not with meals.
Choice B reason: Choosing foods that are high in simple carbohydrates is not recommended for a client who has dumping syndrome. Simple carbohydrates can cause a rapid rise and fall of blood glucose levels, resulting in hypoglycemia and weakness. The nurse should advise the client to choose foods that are high in protein and fat, and low in sugar.
Choice C reason: Staying upright when eating and for 30 minutes afterward is not recommended for a client who has dumping syndrome. This position can facilitate the gastric emptying and worsen the symptoms. The nurse should advise the client to lie down after eating to slow down the gastric emptying.
Choice D reason: Eating several small meals daily spaced at equal intervals is recommended for a client who has dumping syndrome. This can help reduce the gastric volume and pressure, and prevent the rapid delivery of food into the small intestine. The nurse should advise the client to eat four to six small meals per day, and avoid skipping meals.
Correct Answer is C
Explanation
Choice A reason: This is not a correct finding for hypervolemia. Hypotension is a low blood pressure, which can be caused by hypovolemia (low blood volume) or other factors. Hypervolemia is an excess of fluid in the body, which can increase the blood pressure.
Choice B reason: This is not a correct finding for hypervolemia. Bradycardia is a slow heart rate, which can be caused by heart block, medication, or other factors. Hypervolemia can cause tachycardia (fast heart rate) as the heart tries to pump the excess fluid.
Choice C reason: This is a correct finding for hypervolemia. Peripheral edema is a swelling of the extremities due to fluid accumulation in the tissues. Hypervolemia can cause peripheral edema as the fluid leaks from the blood vessels into the interstitial spaces.
Choice D reason: This is not a correct finding for hypervolemia. Weight loss is a decrease in body weight, which can be caused by dehydration, malnutrition, or other factors. Hypervolemia can cause weight gain as the body retains more fluid.
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