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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A continuous seizure state in which seizures occur in rapid succession:
This describes status epilepticus, a medical emergency characterized by prolonged or continuous seizures. It is not related to the concept of an aura.
B. A sensory warning that a seizure is imminent:
This is the correct answer. An aura is a subjective sensation or symptom that acts as a warning sign that a seizure is about to occur. Auras can vary widely among individuals and may include visual, auditory, olfactory, or other sensory experiences.
C. A period of sleepiness following the seizure during which arousal is difficult:
This describes the postictal state, which occurs after a seizure. During this period, the individual may experience confusion, drowsiness, or difficulty arousing from sleep. It is not specifically related to the concept of an aura.
D. A brief loss of consciousness accompanied by staring:
This describes an absence seizure, characterized by a brief loss of awareness and a blank stare. Absence seizures typically do not have an aura preceding them.
Correct Answer is C
Explanation
A. Instruct the client to perform controlled coughing and deep breathing.
This intervention is not appropriate for a client with increased intracranial pressure. Controlled coughing and deep breathing can increase intrathoracic pressure, which can in turn increase intracranial pressure. Therefore, this intervention should be avoided in clients with increased ICP.
B. Provide a brightly lit environment.
This intervention is not appropriate for a client with increased intracranial pressure. Bright lights can stimulate the reticular activating system and increase arousal, potentially exacerbating cerebral metabolic demand and intracranial pressure. Therefore, it is recommended to provide a calm, quiet environment with subdued lighting for clients with increased ICP.
C. Elevate the head of the bed 30°.
This intervention is correct. Elevating the head of the bed to 30 degrees promotes venous drainage from the head and reduces intracranial pressure. It helps prevent venous congestion in the brain and improves cerebral perfusion. This position is commonly used in clients with increased intracranial pressure to optimize cerebral blood flow.
D. Encourage a minimum intake of 2,000 mL/day of clear fluids.
This intervention is not appropriate for a client with increased intracranial pressure. While maintaining hydration is important for overall health, excessive fluid intake can increase intracranial pressure by increasing cerebral blood volume and cerebrospinal fluid production. Therefore, fluid intake should be carefully monitored and adjusted based on the client's condition and fluid balance.
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