A nurse is caring for a client who has dehydration. Which of the following findings should the nurse expect?

Bradycardia

Postural hypotension

Peripheral edema

Distended neck veins

Answer and Explanation

The Correct Answer is B

Dehydration occurs when fluid loss exceeds fluid intake, leading to a reduction in intravascular volume and impaired tissue perfusion. It can result from inadequate intake, excessive losses such as vomiting, diarrhea, or diuretic use, and is characterized by both clinical and hemodynamic changes. Nurses assess for signs of hypovolemia, including vital sign changes, skin turgor, and orthostatic effects. Early recognition is essential to prevent progression to hypovolemic shock.

Rationale:
A. Bradycardia is not typically associated with dehydration. Instead, the body compensates for reduced circulating volume by increasing heart rate to maintain cardiac output and tissue perfusion. A slow heart rate would be more suggestive of other conditions such as medication effects or conduction abnormalities.

B. Postural hypotension is an expected finding in dehydration due to decreased intravascular volume. When the client changes position from lying to standing, there is insufficient fluid volume to maintain blood pressure, leading to dizziness or lightheadedness. This occurs because of impaired vascular compensation and reduced venous return.

C. Peripheral edema is not associated with dehydration because it reflects fluid excess in the interstitial spaces. Dehydration causes fluid loss, leading instead to dry mucous membranes, poor skin turgor, and reduced tissue hydration. Edema is more commonly seen in conditions such as heart failure or renal disease.

D. Distended neck veins indicate increased central venous pressure and fluid overload, not dehydration. In hypovolemic states, jugular veins are typically flat or collapsed due to reduced circulating volume. This finding would be inconsistent with dehydration and suggests an opposite fluid imbalance.

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Correct Answer is B

Explanation

Home safety is a critical component of care for clients who have had a Cerebrovascular accident because they often experience weakness, impaired balance, visual deficits, and decreased coordination. These limitations increase the risk of falls and injuries in the home environment. The nurse’s role is to identify and correct hazards that could contribute to accidents while promoting independence and safety. Environmental modifications are key to reducing preventable harm.

Rationale:
A. Setting the water heater to 54.4°C (130°F) is unsafe because it increases the risk of thermal injury or burns, especially in clients with sensory or mobility impairments. The recommended safe setting is typically lower (around 49°C/120°F) to prevent scalding injuries. This does not promote safety.

B. Replacing burned-out light bulbs is an appropriate safety intervention because adequate lighting reduces the risk of falls and improves mobility in clients with neurological deficits. Good visibility is essential for clients recovering from stroke who may have impaired balance, coordination, or visual field deficits. This directly enhances environmental safety.

C. Running extension cords under throw rugs is unsafe because it creates a tripping hazard and increases the risk of falls. Additionally, covering cords can lead to overheating and potential fire hazards. This practice should be avoided in home safety planning.

D. Ensuring the client wears soft-soled slippers may improve comfort but does not provide optimal safety if the footwear lacks proper support or traction. In stroke clients, supportive, non-slip footwear is recommended to reduce fall risk. Soft slippers may actually increase instability if they do not fit securely.

A. Lung assessment B. Pain rating C. Diminished hearing D. Facial nerve assessment E. Pupils F. Vertigo

Correct Answer is ["C","D","F"]

Explanation

A stapedectomy is a surgical procedure performed to improve conductive hearing loss in clients with otosclerosis by replacing or bypassing the immobilized stapes bone. Postoperative care focuses on monitoring for complications such as inner ear trauma, facial nerve injury, infection, and vestibular dysfunction. Because the surgery involves delicate structures of the middle and inner ear, neurologic and sensory changes must be closely evaluated. Early identification of abnormal findings is essential to prevent permanent deficits.

Rationale:
A. Lung assessment showing clear bilateral breath sounds does not require further action because it is an expected and normal finding. There is no indication of respiratory compromise or postoperative pulmonary complication. Normal lung sounds suggest adequate ventilation and oxygenation status.

B. Pain rating of 5 out of 10 is expected after ear surgery and is not necessarily abnormal if it is controlled with prescribed analgesics. Mild to moderate postoperative pain is common following a stapedectomy due to tissue manipulation. Pain alone, without other concerning signs, does not require urgent intervention.

C. Diminished hearing following surgery requires further action because although temporary changes may occur, worsening or unexpected hearing loss may indicate inner ear injury or prosthesis displacement. Postoperative hearing should be monitored closely to differentiate expected transient changes from complications. Significant or progressive hearing loss warrants immediate evaluation.

D. Facial nerve assessment showing facial droop requires urgent attention because it may indicate facial nerve injury during surgery. The facial nerve runs close to the middle ear structures and can be affected during a stapedectomy. Facial asymmetry is an abnormal neurologic finding that requires prompt notification of the provider.

E. Pupils that are equal, round, and reactive to light are normal postoperative neurological findings and do not require intervention. Stable pupil response indicates intact cranial nerve function and adequate neurological status. No further action is needed for this finding.

F. Vertigo requires further evaluation because it may indicate inner ear disturbance or vestibular involvement following stapedectomy. Mild dizziness can be expected postoperatively, but significant vertigo accompanied by nausea may suggest labyrinthine irritation or complication. This finding should be monitored and reported if persistent or worsening.

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A nurse is caring for a client who has dehydration. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["C","D","F"]

Explanation

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