The assessment that indicates a fluid volume excess in a patient in the acute phase of a CVA is:

adventitious breath sounds

weak pulse

hypotension

poor skin turgor

Answer and Explanation

The Correct Answer is A

A. Adventitious breath sounds:

Adventitious breath sounds refer to abnormal lung sounds heard upon auscultation of the chest. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. In the context of fluid volume excess, particularly in the acute phase of a cerebrovascular accident (CVA) or stroke, adventitious breath sounds such as crackles are indicative of pulmonary edema. Pulmonary edema occurs when there is an excessive accumulation of fluid in the lungs, impairing gas exchange and leading to symptoms such as shortness of breath and respiratory distress.

B. Weak pulse:

A weak pulse may suggest poor perfusion or decreased cardiac output rather than fluid volume excess. While decreased cardiac output can be a consequence of heart failure, which may be associated with fluid volume excess, a weak pulse is not a direct indicator of fluid overload. In the acute phase of a CVA, a weak pulse may prompt further assessment for other cardiovascular complications or neurogenic shock.

C. Hypotension:

Hypotension, or low blood pressure, is not typically associated with fluid volume excess. Instead, hypotension may indicate hypovolemia, shock, or other underlying cardiovascular conditions. While hypotension can occur secondary to severe heart failure or fluid overload in some cases, it is not a direct indicator of fluid volume excess in the acute phase of a CVA.

D. Poor skin turgor:

Poor skin turgor is a clinical finding associated with dehydration rather than fluid volume excess. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. In contrast, fluid volume excess is characterized by edema, which may manifest as pitting or non-pitting edema, rather than poor skin turgor. However, in fluid volume excess, the skin may appear stretched or taut due to the accumulation of fluid in the interstitial spaces.

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Correct Answer is C

Explanation

A. Increased blinking

Increased blinking is not a typical manifestation of bradykinesia. In fact, individuals with Parkinson's disease may experience reduced blinking (hypokinesia of blinking) rather than increased blinking.

B. States of euphoria

Euphoria is not typically associated with bradykinesia. Instead, individuals with Parkinson's disease may experience a range of mood changes, including depression, anxiety, or apathy, but euphoria is not a common finding.

C. Slurred speech

This is the correct answer. Slurred speech, or dysarthria, can occur in individuals with Parkinson's disease as a result of bradykinesia affecting the muscles involved in speech production. Bradykinesia can cause a reduction in the speed and coordination of movements necessary for clear speech, resulting in slurred or mumbled speech patterns.

D. Decreased respiratory rate

Decreased respiratory rate is not typically associated with bradykinesia. Bradykinesia primarily affects voluntary movements rather than involuntary processes such as respiration. While respiratory muscle weakness can occur in advanced stages of Parkinson's disease, it is not directly related to bradykinesia.

A. Provide a suction setup at the bedside. B. Elevate the side rails when in bed. C. Place a bite stick at the bedside. D. Keep an oxygen setup at the bedside. E. Furnish restraints at the bedside.

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

Explanation

A. Provide a suction setup at the bedside:

This is a relevant intervention as it ensures that suction equipment is readily available in case the client experiences excessive secretions or vomiting during or after a seizure. It helps maintain a clear airway and prevent aspiration.

B. Elevate the side rails when in bed:

Elevating the side rails can help ensure the client's safety during a seizure by preventing falls from the bed. It is a preventive measure to minimize the risk of injury.

C. Place a bite stick at the bedside:

Placing a bite stick at the bedside is not a recommended intervention. Bite sticks can potentially injure the patient's teeth or mouth during a seizure and are generally not recommended in current practice.

D. Keep an oxygen setup at the bedside:

This is an appropriate intervention as it ensures that oxygen is readily available in case the client experiences respiratory distress or hypoxia during or after a seizure. Oxygen therapy may be needed to support respiratory function.

E. Furnish restraints at the bedside:

Furnishing restraints at the bedside is not a recommended intervention for managing seizures. Restraints should only be used in exceptional circumstances when the client's safety or the safety of others is at risk and should be applied according to institutional policies and legal regulations.

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The assessment that indicates a fluid volume excess in a patient in the acute phase of a CVA is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has Parkinson's disease and is experiencing bradykinesia. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

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

Explanation

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