A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)
Bounding pulse.
Elevated temperature.
Warmth at IV site.
Profuse sweating.
Crackles in lungs.
Correct Answer : A,E
Choice A reason: A bounding pulse can indicate fluid volume excess, as the heart works harder to pump the increased volume.
Choice B reason: Elevated temperature is not specifically indicative of fluid volume excess and can be related to various conditions.
Choice C reason: Warmth at the IV site may indicate an infection or inflammation, not necessarily fluid volume excess.
Choice D reason: Profuse sweating is not typically a sign of fluid volume excess; instead, it may indicate dehydration or other conditions.
Choice E reason: Crackles in the lungs can indicate fluid overload, especially in the context of excessive IV fluid administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: An illusion is a misinterpretation of a real external stimulus, which is not the case here as there is no snake.
Choice B reason: Attention-getting behavior is a possibility, but given that Mr. G is specifically referencing a snake that isn't there, it suggests a hallucination.
Choice C reason: A hallucination is a sensory perception in the absence of external stimuli, which fits Mr. G's description of seeing a snake that isn't there.
Choice D reason: A delusion is a firmly held false belief; while Mr. G may have this, the immediate experience he's describing is a hallucination, not a delusion.
Correct Answer is A
Explanation
Choice A reason: Catatonia is characterized by symptoms such as extreme muscle rigidity, repetitive speech, and resistance to movement, which align with Lisa's presentation. It is often associated with other mental health conditions but can also be a standalone diagnosis.
Choice B reason: Disorganized schizophrenia is marked by disorganized thinking and behavior, inappropriate emotional responses, and erratic actions. While Lisa's symptoms could suggest a psychotic disorder, they do not specifically indicate disorganized schizophrenia.
Choice C reason: Schizotypal disorder involves eccentric behavior, odd beliefs, and difficulty forming close relationships. Lisa's symptoms do not align with the core characteristics of schizotypal disorder.
Choice D reason: Brief psychotic disorder is a short-term condition that includes delusions, hallucinations, and disorganized speech. Lisa's symptoms could be part of a brief psychotic episode, but the specific mention of muscle rigidity and resistance to movement is more indicative of catatonia.
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