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Exhibits

The nurse reviews the intake information prior to seeing the client.

What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

Temperature 99.9° F (37.7° C)

Respirations 34 breaths/minute

Heart rate 136 beats/minute

Weak peripheral pulses

Dry mucous membranes

Body mass index (BMI) 21.9 kg/m2

Blood pressure 100/52 mm Hg

Poor skin turgor

Answer and Explanation

Correct Answer : C,D,E,G,H

A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.

B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.

C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.

D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.

E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.

F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.

G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.

H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.

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Correct Answer is ["A","B"]

Explanation

A. History of hypertension: Although the client’s current blood pressure is controlled with atenolol, the need for medication confirms a history of hypertension. Hypertension is a major modifiable risk factor for coronary artery disease and warrants ongoing assessment.

B. Family health history: A strong family history of heart disease and diabetes, particularly in first-degree relatives, significantly increases the client’s risk for cardiovascular events. The genetic predisposition should be explored to assess early markers and implement prevention strategies.

C. Vegetarian diet: A vegetarian diet is generally associated with lower cardiovascular risk due to reduced intake of saturated fats and cholesterol. Unless the diet is poorly balanced or nutrient-deficient, it does not constitute a risk factor that requires further evaluation here.

D. Sexual history: Sexual history may be relevant in certain clinical contexts, such as evaluating HIV risk or sexually transmitted infections, but it is not directly related to the client's cardiac symptoms or concern about hereditary heart disease.

E. Excessive aerobic exercise: The client’s activity level (jogging) is not excessive and is generally healthy, unless it is associated with overtraining or extreme exertion. There is no indication here that excessive exercise is a concern, so further exploration is not needed based on this information.

A. 4-2-1-1-4 B. 5-2-1-1-4 C. 4-3-1-0-4 D. 5-3-1-0-4

Correct Answer is B

Explanation

A. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.

B. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.

C. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.

D. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.

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Exhibits The nurse reviews the intake information prior to seeing the client. What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B"]

Explanation

Correct Answer is B

Explanation

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Exhibits

The nurse reviews the intake information prior to seeing the client.

What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.