A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?
Decreased heart rate
Increased blood pressure
Weak pulse
Dyspnea
The Correct Answer is C
Choice A reason: Decreased heart rate is not a manifestation of hypovolemia. Hypovolemia is a condition where there is a decreased volume of blood in the body, which can result from blood loss, dehydration, or fluid shifts. Hypovolemia can cause the heart rate to increase, not decrease, as the body tries to compensate for the low blood pressure and maintain adequate perfusion.
Choice B reason: Increased blood pressure is not a manifestation of hypovolemia. Hypovolemia can cause the blood pressure to decrease, not increase, as the blood volume and cardiac output are reduced. The body may try to constrict the blood vessels to increase the blood pressure, but this is usually not enough to overcome the effects of hypovolemia.
Choice C reason: Weak pulse is a manifestation of hypovolemia. Hypovolemia can cause the pulse to become weak, thready, or difficult to palpate, as the blood flow and pressure are diminished. The pulse may also become irregular or rapid, as the heart tries to pump faster and harder to deliver oxygen to the tissues.
Choice D reason: Dyspnea is not a specific manifestation of hypovolemia. Dyspnea is a term for difficulty breathing, which can have many causes, such as asthma, pneumonia, or pulmonary edema. Hypovolemia can cause dyspnea if it leads to shock, which is a life-threatening condition where the organs and tissues are not receiving enough oxygen. However, dyspnea alone is not enough to indicate hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the best response because it is alarmist and does not address the client's concern. The nurse should not assume that the client needs to have their medications adjusted or be admitted to the hospital without further assessment.
Choice B reason: This is not the best response because it is inaccurate and does not explain the link between urine retention and confusion. The nurse should not imply that the client is causing their own confusion by not drinking enough water.
Choice C reason: This is the best response because it is accurate and educates the client on the effects of dehydration on the body. The nurse should encourage the client to drink more fluids throughout the day and offer strategies to make it easier for them to access the bathroom at night.
Choice D reason: This is not the best response because it is irrelevant and does not address the client's dehydration. The nurse should not suggest that the client has a urinary tract infection without evidence or testing. The nurse should also not discourage the client from urinating at night, as this can lead to other complications.
Correct Answer is A
Explanation
Choice A reason: Colonoscopy is the most accurate diagnostic test for diverticulosis, which is the presence of pouches or sacs in the wall of the colon. It allows the direct visualization of the colon and the identification of any diverticula, polyps, or tumors. The nurse should prepare the client to undergo bowel preparation, sedation, and monitoring before and after the procedure.
Choice B reason: Magnetic resonance imaging (MRI) is not a diagnostic test for diverticulosis. It is a non-invasive imaging technique that uses a magnetic field and radio waves to create detailed images of the internal organs and tissues. It is more commonly used for brain, spine, joint, or soft tissue disorders.
Choice C reason: Abdominal ultrasound is not a diagnostic test for diverticulosis. It is a non-invasive imaging technique that uses sound waves to create images of the abdominal organs and structures. It is more commonly used for liver, gallbladder, kidney, or spleen disorders.
Choice D reason: Computed tomography (CT) scan with contrast is not a diagnostic test for diverticulosis. It is an invasive imaging technique that uses x-rays and a contrast dye to create cross-sectional images of the body. It is more commonly used for detecting tumors, abscesses, or bleeding. It is also used for diagnosing diverticulitis, which is the inflammation or infection of the diverticula.
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