A nurse is collecting data from a patient who has dehydration. Which of the following findings should the nurse expect?
Moist skin
Dark-colored urine
High blood pressure
Distended neck veins
The Correct Answer is B
Choice A reason: Moist skin is not a sign of dehydration, but rather a sign of adequate hydration or sweating. Dehydration can cause dry skin, mucous membranes, and lips.
Choice B reason: Dark-colored urine is a sign of dehydration, as it indicates a high concentration of waste products and a low volume of water in the urine. Dehydration can cause the kidneys to conserve water and produce less urine.
Choice C reason: High blood pressure is not a sign of dehydration, but rather a sign of fluid overload or other factors such as stress, pain, or medication. Dehydration can cause low blood pressure, as it reduces the blood volume and the cardiac output.
Choice D reason: Distended neck veins are not a sign of dehydration, but rather a sign of fluid overload or right-sided heart failure. Dehydration can cause flat neck veins, as it reduces the venous return and the central venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Sodium (Na+) imbalance can cause neurological symptoms such as confusion, seizures, or coma, but not abdominal pain or urinary retention.
Choice B reason: Calcium (Ca2+) imbalance can cause abdominal pain, urinary retention, and confusion, as well as muscle weakness, bone pain, and cardiac arrhythmias. These signs are the result of an inadequate supply of calcium, which is essential for nerve and muscle function, as well as bone health.
Choice C reason: Chloride (Cl-) imbalance can cause acid-base disorders such as metabolic acidosis or alkalosis, but not abdominal pain, urinary retention, or confusion.
Choice D reason: Phosphates (PO4^3^-) imbalance can cause bone and muscle problems, such as rickets, osteomalacia, or tetany, but not abdominal pain, urinary retention, or confusion.
Choice E reason: Potassium (K+) imbalance can cause cardiac and neuromuscular symptoms, such as arrhythmias, palpitations, muscle weakness, or paralysis, but not abdominal pain, urinary retention, or confusion.
Correct Answer is D
Explanation
Choice A reason: Intracellular to the extracellular fluid shift is not the cause of low blood pressure in this case. This fluid shift occurs when the cells lose water due to osmosis, such as in dehydration or hypernatremia.
Choice B reason: Interstitial to intravascular fluid shift is not the cause of low blood pressure in this case. This fluid shift occurs when the fluid moves from the tissue spaces to the blood vessels, such as in hypovolemia or hypotonic fluid administration.
Choice C reason: Interstitial to the intracellular fluid shift is not the cause of low blood pressure in this case. This fluid shift occurs when the fluid moves from the tissue spaces to the cells, such as in overhydration or hyponatremia.
Choice D reason: Intravascular to the interstitial fluid shift is the cause of low blood pressure in this case. This fluid shift occurs when the fluid moves from the blood vessels to the tissue spaces, such as in edema, inflammation, or increased capillary permeability. This reduces the blood volume and lowers the blood pressure.
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