A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)

Increased temperature

Increased respiratory rate

Increased hematocrit

Increased heart rate

Increased blood pressure

Answer and Explanation

Correct Answer : A,B,C

Choice A: Increased Respiratory Rate

Fluid overload, also known as hypervolemia, can lead to an increased respiratory rate. This occurs because the excess fluid in the body can accumulate in the lungs, leading to pulmonary congestion and edema. As a result, the body attempts to compensate by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide. Normal respiratory rate for adults is typically between 12-20 breaths per minute. An increased respiratory rate above this range can indicate fluid overload.

Choice B: Increased Heart Rate

An increased heart rate, or tachycardia, is another common finding in clients with fluid overload. The heart has to work harder to pump the excess fluid throughout the body, leading to an increased heart rate. This is a compensatory mechanism to maintain adequate cardiac output and tissue perfusion. Normal resting heart rate for adults is between 60-100 beats per minute. A heart rate above this range can be indicative of fluid overload.

Choice C: Increased Blood Pressure

Fluid overload can also result in increased blood pressure, or hypertension. The excess fluid in the bloodstream increases the volume of blood that the heart has to pump, leading to higher pressure within the arteries. This can strain the cardiovascular system and lead to complications if not managed properly. Normal blood pressure is typically around 120/80 mmHg. Blood pressure readings consistently above this range can suggest fluid overload.

Choice D: Increased Hematocrit

Increased hematocrit is not typically associated with fluid overload. Hematocrit is the proportion of red blood cells in the blood. In cases of fluid overload, the hematocrit level is usually decreased due to the dilutional effect of the excess fluid. Therefore, this choice is incorrect.

Choice E: Increased Temperature

Increased temperature is not a common finding in fluid overload. Fever or elevated body temperature is more commonly associated with infections or inflammatory conditions. Fluid overload does not typically cause an increase in body temperature. Therefore, this choice is incorrect.

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

Explanation

Choice A reason: A buffalo hump is a characteristic sign of Cushing’s syndrome. It refers to the accumulation of fat on the back of the neck and shoulders. This symptom occurs due to the excessive production of cortisol, which leads to abnormal fat distribution in the body.

Choice B reason: Moon face is another hallmark of Cushing’s syndrome. It describes the rounding and fullness of the face, which results from fat deposits. This symptom is also caused by prolonged exposure to high levels of cortisol.

Choice C reason: Hypertension, or high blood pressure, is commonly associated with Cushing’s syndrome. Cortisol increases blood pressure by enhancing the sensitivity of blood vessels to catecholamines and by promoting sodium and water retention.

Choice D reason: Purple striations, or stretch marks, are often seen in individuals with Cushing’s syndrome. These marks typically appear on the abdomen, thighs, breasts, and arms. They result from the thinning of the skin and the breakdown of collagen due to elevated cortisol levels.

Choice E reason: Tremors are not typically associated with Cushing’s syndrome. While Cushing’s syndrome can cause a variety of symptoms, tremors are more commonly linked to other conditions such as hyperthyroidism or neurological disorders.

A. Ammonia B. Muscle rigidity C. Seizures D. Drooling at times E. Mask-like facial expression F. Shuffled gait

Correct Answer is A

Explanation

Choice A: Ammonia

Lactulose is administered to patients with hepatic encephalopathy to reduce the levels of ammonia in the blood. Hepatic encephalopathy occurs due to the liver’s inability to detoxify ammonia, a byproduct of protein metabolism. Lactulose works by converting ammonia into ammonium, which is then excreted in the stool. This helps to lower blood ammonia levels and alleviate the symptoms of hepatic encephalopathy.

Choice B: Dysarthria

Dysarthria, or difficulty in articulating words, is a common symptom of Parkinson’s disease. It results from the muscle rigidity and bradykinesia (slowness of movement) that affect the muscles involved in speech. Patients with Parkinson’s often have a soft, monotone voice and may struggle with the clarity of their speech.

Choice C: Muscle Rigidity

Muscle rigidity is one of the hallmark symptoms of Parkinson’s disease. It refers to the stiffness and inflexibility of the muscles, which can affect any part of the body. This rigidity can lead to discomfort and pain, and it contributes to the characteristic stooped posture and shuffling gait seen in Parkinson’s patients.

Choice D: Seizures

Seizures are not typically associated with Parkinson’s disease. While Parkinson’s affects the central nervous system, it primarily impacts motor function rather than causing seizure activity. Therefore, this is not a common finding in Parkinson’s patients.

Choice E: Drooling at Times

Drooling, or sialorrhea, is a common symptom in Parkinson’s disease. It occurs due to the decreased ability to swallow saliva, which can result from muscle rigidity and bradykinesia affecting the muscles involved in swallowing. This can be particularly bothersome for patients and may require management strategies.

Choice F: Mask-like Facial Expression

A mask-like facial expression, also known as hypomimia, is a common feature of Parkinson’s disease. It results from the rigidity and bradykinesia affecting the facial muscles, leading to reduced facial expressions and a fixed, staring appearance.

Choice G: Shuffled Gait

A shuffled gait is a characteristic feature of Parkinson’s disease. Patients often take small, shuffling steps and may have difficulty initiating movement. This gait pattern is due to the combination of muscle rigidity, bradykinesia, and postural instability.

Choice H: Stooped Posture

Stooped posture is another common symptom of Parkinson’s disease. It results from the muscle rigidity and postural instability that affect the patient’s ability to maintain an upright position. This can lead to a forward-leaning posture and balance issues.

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A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is A

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