A nurse is caring for a patient hospitalized with acute kidney injury (AKI). The healthcare provider has ordered daily weights and strict intake and output monitoring. The nurse notes that the patient has gained 3 pounds over the past 48 hours, with minimal urine output recorded during that time. What does this assessment finding most likely indicate?
The patient is experiencing improved nutritional status
The weight gain is expected and not clinically significant
The patient is showing early signs of recovery from AKI
The patient may be retaining fluid due to AKI
The Correct Answer is D
Choice A reason: Improved nutritional status could cause weight gain but is unlikely in AKI with minimal urine output. AKI patients often have anorexia or dietary restrictions, and weight gain from nutrition would not align with oliguria, which suggests fluid retention rather than increased tissue mass from improved nutrition.
Choice B reason: A 3-pound weight gain in 48 hours with minimal urine output is clinically significant in AKI, indicating fluid retention. Normal weight fluctuations are minimal, and this rapid gain, coupled with oliguria, suggests impaired kidney function, potentially leading to fluid overload complications like hypertension or pulmonary edema.
Choice C reason: Early AKI recovery involves increased urine output (diuresis phase), not minimal output. Weight gain with oliguria indicates ongoing kidney dysfunction, not recovery. Recovery would show improved glomerular filtration and urine production, reducing fluid retention, making this finding inconsistent with AKI recovery.
Choice D reason: In AKI, minimal urine output (oliguria) reflects impaired kidney filtration, leading to fluid retention. A 3-pound weight gain in 48 hours corresponds to approximately 1.5 liters of fluid, indicating fluid overload. This can cause hypertension, pulmonary edema, or heart failure, making fluid retention the most likely explanation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Legislation changing civil commitment procedures occurred later, notably in the 1960s–1970s, with deinstitutionalization movements. In the 1950s, institutional care was still prevalent, and legislative reforms were not the primary change in mental health treatment, making this option incorrect for that decade.
Choice B reason: Community support services expanded significantly during the 1960s with deinstitutionalization, not the 1950s. While some early community efforts existed, they were not the hallmark change of the 1950s, when institutional care dominated, and psychotropic drugs revolutionized treatment approaches for mental illness.
Choice C reason: The Patient’s Bill of Rights was formalized in the 1970s, not the 1950s. While patient advocacy began to emerge later, the 1950s focused primarily on medical advancements like psychotropic drugs, not legal frameworks for patient rights, making this option incorrect.
Choice D reason: In the 1950s, psychotropic drugs like chlorpromazine were introduced, revolutionizing mental health treatment. These medications effectively managed psychosis, reducing symptoms and enabling outpatient care, decreasing reliance on long-term institutionalization. This marked a significant shift in psychiatric care, making it the key change of the decade.
Correct Answer is A
Explanation
Choice A reason: A 201 status indicates voluntary admission to a mental health facility, where the client can request discharge by signing a withdrawal form, typically with a 72-hour notice period. This matches the client’s statement, as voluntary patients retain control over their discharge, consistent with mental health laws.
Choice B reason: A 303 status involves extended involuntary commitment for ongoing treatment, typically after a court hearing. It does not allow self-initiated discharge by signing a form, as the client’s statement suggests, making this status incompatible with the described ability to request withdrawal.
Choice C reason: A 302 status is an involuntary commitment for imminent danger, requiring medical or legal approval for discharge, not a simple request form. The client’s ability to sign for withdrawal indicates voluntary status, making 302 incorrect for this scenario.
Choice D reason: A 301 status is not a standard term in mental health commitment laws (e.g., Pennsylvania’s Mental Health Procedures Act). The client’s ability to request discharge aligns with voluntary (201) status, not an undefined or involuntary category, making this option incorrect.
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