A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?
Blood pressure 178/90 mm Hg
Edema
Bounding bilateral pulses
Increased urine specific gravity
The Correct Answer is D
A) Blood pressure 178/90 mm Hg: Elevated blood pressure is more commonly associated with fluid overload or hypertension rather than dehydration. In dehydration, one would expect to see a decrease in blood pressure, particularly orthostatic hypotension, due to a reduction in blood volume.
B) Edema: Edema indicates fluid retention in the tissues, which is a sign of fluid overload rather than dehydration. Dehydration typically results in reduced extracellular fluid volume, leading to symptoms like dry mucous membranes and poor skin turgor, rather than swelling.
C) Bounding bilateral pulses: Bounding pulses are usually seen in conditions of increased cardiac output or fluid overload, where there is an excess of fluid volume. In contrast, dehydration often leads to weak and thready pulses due to decreased circulatory volume.
D) Increased urine specific gravity: Increased urine specific gravity is a direct indicator of dehydration. It occurs because the kidneys concentrate urine to conserve water, leading to a higher concentration of solutes in the urine. This is a reliable clinical marker of reduced hydration status, reflecting the body's attempt to maintain fluid balance by conserving water.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Hyperactive bowel sounds: Hypercalcemia typically leads to decreased gastrointestinal motility, not increased. Clients with elevated calcium levels may experience constipation, abdominal pain, or ileus due to the relaxing effect of calcium on smooth muscle. Therefore, hyperactive bowel sounds are not a common finding in hypercalcemia.
B) Increased blood clots: Hypercalcemia can promote a hypercoagulable state, increasing the risk of thromboembolic events. This occurs because high calcium levels can enhance platelet aggregation and increase the coagulability of blood. Therefore, a client with elevated serum calcium may have an increased risk of developing blood clots.
C) Hyperactive deep tendon reflexes: Hypercalcemia generally leads to reduced neuromuscular excitability, which may manifest as decreased or absent deep tendon reflexes, muscle weakness, and lethargy. Hyperactive reflexes are more commonly associated with hypocalcemia, which causes increased neuromuscular excitability.
D) Positive Chvostek’s sign: Chvostek's sign is a clinical indicator of hypocalcemia, not hypercalcemia. It involves twitching of the facial muscles in response to tapping the facial nerve and is due to increased neuromuscular excitability caused by low calcium levels. Hypercalcemia, conversely, does not typically present with a positive Chvostek’s sign.
Correct Answer is A
Explanation
A) Speech Therapist: A speech therapist is the appropriate professional for assessing and managing dysphagia, especially in clients who have experienced a stroke. They specialize in evaluating swallowing function, determining the safest consistencies of food and liquids, and providing strategies or exercises to improve swallowing ability. They play a critical role in deciding the safest method of feeding, whether it involves modified diets or alternative feeding methods.
B) Respiratory Therapist: Respiratory therapists focus on assessing and managing respiratory conditions. While they may become involved if there are concerns about aspiration leading to respiratory complications, they do not directly manage dysphagia or feeding issues.
C) Physical Therapist: Physical therapists work primarily on improving gross motor skills, mobility, and physical function. They do not specialize in swallowing disorders or feeding methods, so they are not the primary professionals to consult for issues related to dysphagia.
D) Occupational Therapist: Occupational therapists can assist clients with fine motor skills and daily living activities, which may include feeding. However, they do not specialize in assessing or treating swallowing disorders. Their role would be more focused on helping clients with the practical aspects of self-feeding once safe swallowing methods are established by a speech therapist.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.