A nurse is caring for a client who has fluid volume excess (FVE) due to heart failure (HF). Which of the following manifestations should the nurse associate with FVE? (Select all that apply.)
Thready pulse
Dizziness
Pedal edema
Flat neck veins
weight gain
Correct Answer : C,E
Rationale:
A. A thready, weak pulse is typically associated with fluid volume deficit, not excess. Clients with FVE often have bounding pulses due to increased intravascular volume.
B. Dizziness is more commonly a sign of hypovolemia or hypotension, rather than fluid overload.
C. Edema occurs when excess fluid accumulates in the interstitial spaces, commonly in the lower extremities in clients with heart failure, making it a classic manifestation of FVE.
D. FVE usually causes distended (full) neck veins due to increased central venous pressure. Flat neck veins are associated with hypovolemia.
E. Rapid or unexplained weight gain in a client with HF is an early sign of fluid retention and is commonly used to monitor FVE.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Rationale:
A. A thready, weak pulse is typically associated with fluid volume deficit, not excess. Clients with FVE often have bounding pulses due to increased intravascular volume.
B. Dizziness is more commonly a sign of hypovolemia or hypotension, rather than fluid overload.
C. Edema occurs when excess fluid accumulates in the interstitial spaces, commonly in the lower extremities in clients with heart failure, making it a classic manifestation of FVE.
D. FVE usually causes distended (full) neck veins due to increased central venous pressure. Flat neck veins are associated with hypovolemia.
E. Rapid or unexplained weight gain in a client with HF is an early sign of fluid retention and is commonly used to monitor FVE.
Correct Answer is A
Explanation
Rationale:
A. In first-degree atrioventricular (AV) block, all atrial impulses reach the ventricles, but conduction through the AV node is delayed. This delay is reflected on the ECG as a PR interval longer than 0.20 seconds, while the QRS complex remains normal. First-degree AV block is usually asymptomatic and often does not require treatment.
B. This description fits second-degree AV block, not first-degree. In first-degree block, no impulses are blocked, only delayed.
C. First-degree AV block is generally asymptomatic, and patients rarely experience symptoms. Symptoms such as syncope are more characteristic of higher-degree AV blocks.
D. Pacemaker therapy is not indicated for first-degree AV block unless it progresses to higher-degree AV block with symptomatic bradycardia. Immediate intervention is not needed in asymptomatic patients.
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