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 B

Explanation

A. Excessive salivation:

Excessive salivation is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine often cause dry mouth, which is more common than excessive salivation.

B. Difficulty voiding:

Difficulty voiding, or urinary retention, is a potential adverse effect of anticholinergic medications like benztropine. Anticholinergic drugs can cause relaxation of the detrusor muscle in the bladder, leading to urinary retention. Therefore, the nurse should instruct the client to report any difficulty or inability to urinate.

C. Diarrhea:

Diarrhea is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine typically cause constipation due to their antimuscarinic effects on the gastrointestinal tract.

D. Slow pulse:

Slow pulse, or bradycardia, is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine may cause tachycardia (increased heart rate) due to their effects on the autonomic nervous system.

A. Dizziness and problems with balance B. Slow papillary response to light C. Jerky eye movements D. Absence of the Achilles tendon jerk

Correct Answer is D

Explanation

A. Dizziness and problems with balance

While dizziness and problems with balance can occur more frequently in older adults due to age-related changes in the vestibular system and other factors, persistent or severe dizziness or balance issues should be evaluated further as they could indicate underlying neurological or medical conditions.

B. Slow papillary response to light

This finding may be considered abnormal, especially if it represents a significant change from the individual's baseline. While age-related changes in pupil function can occur, a slow or sluggish pupillary response to light may indicate dysfunction of the oculomotor nerve or other neurological issues and should be investigated further.

C. Jerky eye movements

Jerky eye movements, such as nystagmus, can be abnormal and may indicate dysfunction of the vestibular system or other neurological conditions. While some degree of nystagmus can occur with age, persistent or severe jerky eye movements should be evaluated further.

D. Absence of the Achilles tendon jerk

This finding may also be considered abnormal. The Achilles tendon reflex, tested using the deep tendon reflex (DTR) examination, can diminish with age but should not be completely absent in the absence of specific medical conditions affecting the reflex arc or spinal cord function.

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

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Explanation

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