A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Weight loss

Decreased blood pressure

Decreased skin turgor

Crackles heard in the lungs

Answer and Explanation

The Correct Answer is D

A.   Incorrect. Weight loss is not a manifestation of fluid overload but rather of insufficient nutrition.
B.   Incorrect. Decreased blood pressure is not a manifestation of fluid overload but could indicate hypovolemia.
C.   Incorrect. Decreased skin turgor is a sign of dehydration, not fluid overload.
D.   Correct. Crackles heard in the lungs can indicate fluid overload in the lungs, also known as pulmonary edema. This is often caused by an excess of fluid in the body.

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Correct Answer is A

Explanation

A. Correct. Observing the client during and after meals is a priority because clients with bulimia nervosa often engage in episodes of binge eating followed by purging behaviors. Monitoring the client's behavior during meals and immediately after can help assess for potential purging behaviors.
B. Incorrect. While involving the client in meal planning might be helpful, it is not the first action to address potential purging behaviors.
C. Incorrect. Instructing the client about effective coping strategies is important, but observing for potential purging behaviors is the initial action to address the client's immediate safety.
D. Incorrect. Referring the client to a support group is beneficial, but it is not the first action to address the client's immediate risk of purging behaviors.

A. Peeling of the hands and feet B. Fever C. Beefy, red tongue D. Facial erythema

Correct Answer is B

Explanation

The correct answer is choiceB. Fever.

Choice A rationale:

Peeling of the hands and feet is not a typical manifestation of pertussis.This symptom is more commonly associated with conditions like Kawasaki disease.

Choice B rationale:

Fever is a common symptom in the early stages of pertussis, along with a mild cough and runny nose.

Choice C rationale:

A beefy, red tongue is not associated with pertussis.This symptom is more characteristic of scarlet fever.

Choice D rationale:

Facial erythema is not a typical symptom of pertussis.Pertussis primarily affects the respiratory system, causing severe coughing fits.

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A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

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