quick Support- Getscreen.me sunny 5 go.getscreen.me/turbo/942218687 HESI A10:36 - MPL-LC2-12- Gets Creer X Question 38 of 85 1320798 Q Lahr 25min 33s remaining O A Lung sounds. OB Turgor. A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance? C Weight. D Blood pressure. Copyright 2024 Elsevier inc., its licensors, and contributors. All rights are reserved, including those for text and data mining. Al training, and similar technologies. Q Search Having Trouble? Contact Support Submit answer and casualize Exam Submit and Continue Show calculator ENG INTL VL380
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A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?
Lung sounds.
Turgor.
Weight.
Blood pressure.
Here's the edited text with the instructions applied:
The Correct Answer is C
Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.
Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.
Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.
Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.
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Correct Answer is B
Explanation
Choice A reason: Palpating the lymph nodes is not a standard technique for assessing early signs of rheumatoid arthritis. Lymph node enlargement can occur due to various reasons, but it is not specific to rheumatoid arthritis.
Choice B reason: Observing the client's fingers is crucial because early signs of rheumatoid arthritis often present in the small joints of the hands and fingers. Symptoms such as swelling, redness, stiffness, and deformities can be evident in these areas.
Choice C reason: Observing the skin for lesions is not specific to rheumatoid arthritis. While some skin conditions can be associated with autoimmune diseases, rheumatoid arthritis primarily affects the joints.
Choice D reason: Palpating large joints for nodules might be relevant in more advanced stages of rheumatoid arthritis, but early signs are typically observed in the small joints of the hands and fingers.
Correct Answer is D
Explanation
Choice A reason: Reducing the client's interaction with others during the day can potentially isolate the client and exacerbate feelings of agitation and confusion. Social interaction is important for cognitive stimulation and emotional well-being, even for clients with Alzheimer's disease.
Choice B reason: Awaking the client for reality checks every 4 hours at night can disrupt the client's sleep pattern, leading to increased agitation and confusion. Proper rest is crucial for clients with Alzheimer's disease to help manage their symptoms effectively.
Choice C reason: Clarifying reality with the client about delusional thoughts can sometimes increase agitation if not done sensitively. Clients with Alzheimer's disease may not respond well to direct confrontation about their delusions. It is often more effective to use techniques that do not directly challenge their perception of reality.
Choice D reason: Using distraction and therapeutic communication skills is the best approach. This strategy helps redirect the client's attention to a different, more calming activity, which can reduce agitation. Therapeutic communication involves understanding and validating the client's feelings while gently guiding them towards a more positive state. This approach respects the client's experience and provides support without escalating their agitation.
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