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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A.Computerized tomography angiography (CTA)

This is a likely diagnostic test that the provider may prescribe. CTA uses computed tomography (CT) imaging to visualize the blood vessels in the brain and neck. It can help identify areas of stenosis, occlusion, or other abnormalities in the blood vessels that may contribute to the TIA symptoms.

B. Complete blood count (CBC)

A complete blood count (CBC) is a routine laboratory test that assesses various components of blood, such as red blood cells, white blood cells, and platelets. While it may not be specific to diagnosing a transient ischemic attack (TIA), it can help evaluate for underlying conditions such as anemia or thrombocytosis that could contribute to TIA symptoms or increase the risk of stroke.

C. Prothrombin time (PT)

Prothrombin time (PT) is a laboratory test that evaluates the clotting ability of blood and is typically used to monitor anticoagulant therapy. While abnormal coagulation parameters may be associated with certain conditions that predispose to TIA (such as atrial fibrillation), PT alone is not a specific diagnostic test for TIA.

D. Transesophageal echocardiogram (TEE)

This is another possible diagnostic test that the provider may prescribe. TEE is a specialized echocardiogram that provides detailed images of the heart structures by inserting an ultrasound probe

A. "These drugs inhibit the action of acetylcholine B. "These drugs help you urinate." C. "These drugs will decrease your eye pressure." D. "These drugs will assist in lowering your heart rate."

Correct Answer is A

Explanation

A. "These drugs inhibit the action of acetylcholine":

This response is accurate. Anticholinergic medications work by blocking the action of acetylcholine, a neurotransmitter involved in various functions in the body, including muscle control. In Parkinson's disease, there is an imbalance between dopamine and acetylcholine, leading to motor symptoms such as tremors and rigidity. By inhibiting the action of acetylcholine, anticholinergic drugs help rebalance neurotransmitter activity and alleviate some of the motor symptoms associated with Parkinson's disease.

B. "These drugs help you urinate":

This statement is not directly related to the use of anticholinergic medications in Parkinson's disease. While some anticholinergic drugs can indeed relax the smooth muscle of the bladder and improve urinary symptoms, this is not the primary indication for their use in Parkinson's disease.

C. "These drugs will decrease your eye pressure":

While anticholinergic medications can be used to dilate the pupils and decrease intraocular pressure, this is not typically the reason for their use in Parkinson's disease. While some anticholinergic medications may have ocular effects, they are primarily used to address motor symptoms associated with Parkinson's disease.

D. "These drugs will assist in lowering your heart rate":

While some anticholinergic medications may have effects on heart rate by blocking parasympathetic nervous system activity, this is not the primary indication for their use in Parkinson's disease. The focus of anticholinergic therapy in Parkinson's disease is primarily on addressing motor symptoms rather than cardiovascular effects.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client in the emergency department who has a preliminary diagnosis of a transient ischemic attack (TIA). Which of the following diagnostic testing should the nurse anticipate the provider to prescribe?

Correct Answer is A

Explanation

A patient with Parkinson's disease asks the nurse why anticholinergics are used in the treatment. Which response by the nurse is most accurate?

Correct Answer is A

Explanation

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?

The nurse documents an abnormal finding from the Babinski reflex as a (the):

A nurse is reinforcing teaching with a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

Which reason explains why a patient with amyotrophic lateral sclerosis (ALS) is uniquely prone to depression?

A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?