The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

Jugular vein distention

Skin turgor, tenting at clavicular area

Elevated hematocrit

Oral mucous membranes dry and sticky

Answer and Explanation

Correct Answer : B,C,D

A. Jugular vein distention: Jugular vein distention is not typically associated with deficient fluid volume (dehydration). Instead, it is often seen in conditions of fluid overload, such as heart failure or volume overload. Therefore, this finding is not accurate for deficient fluid volume.

B. Skin turgor, tenting at clavicular area: Skin turgor refers to the skin's ability to return to its normal position after being pinched or pulled. In cases of deficient fluid volume (dehydration), skin turgor is decreased, leading to delayed return of the skin to its normal state. Tenting at the clavicular area is a specific sign of decreased skin turgor and is indicative of dehydration.

C. Elevated hematocrit: Deficient fluid volume (dehydration) leads to hemoconcentration, where there is a relative increase in the proportion of red blood cells to plasma volume. As a result, the hematocrit level, which represents the percentage of red blood cells in the total blood volume, increases. An elevated hematocrit is a laboratory finding commonly associated with deficient fluid volume.

D. Oral mucous membranes dry and sticky: Dehydration can lead to decreased saliva production and dryness of the oral mucous membranes. Dry and sticky oral mucous membranes are common clinical signs of deficient fluid volume (dehydration) and indicate inadequate fluid intake or loss.

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Correct Answer is D

Explanation

A. Diarrhea: Diarrhea typically involves the passage of loose or watery stools, often occurring frequently throughout the day. It is characterized by increased frequency, urgency, and volume of stool output. While diarrhea can cause bloating, it is not usually associated with continuous oozing of small amounts of liquid stool.

B. Flatus: Flatus refers to the passage of gas through the rectum, commonly known as "passing gas" or "flatulence." While flatus can contribute to feelings of bloating or discomfort, it does not involve the continuous oozing of liquid stool.

C. Overflow: Overflow typically occurs in the context of fecal impaction, where liquid stool leaks around a fecal mass that is blocking the rectum. However, overflow is characterized by the intermittent leakage of liquid stool, often preceded by constipation and fecal impaction. Continuous oozing of small amounts of liquid stool is not typically associated with overflow alone.

D. Impaction: Fecal impaction occurs when a large, hardened mass of stool accumulates in the rectum, making it difficult or impossible to pass stool. Continuous oozing of small amounts of liquid stool can occur around the impacted fecal mass, leading to symptoms such as bloating, discomfort, and leakage of liquid stool. Therefore, fecal impaction is the most likely condition associated with the client's symptoms.

In summary, option D (Impaction) is the correct answer as it best aligns with the client's symptoms of feeling bloated and experiencing continuous oozing of small amounts of liquid stool in the context of being on bedrest after surgery

A. "How often do you punish him by giving him a time-out or by using physical discipline?" B. "Physical punishment is not the best way to modify a child's behavior." C. "It isn't unusual for him to fondle his genitals, as this is part of his exploration of his body." D. "Constantly touching the genitals indicates a urinary tract infection in a toddler." E. "Give him a little time, and he'll grow out of it. He's just too young to understand right now."

Correct Answer is ["B","C","E"]

Explanation

A. "How often do you punish him by giving him a time-out or by using physical discipline?": This response focuses on the mother's disciplinary methods rather than addressing the child's behavior directly. It may come across as judgmental or critical of the mother's parenting approach and does not provide helpful guidance or support.

B. "Physical punishment is not the best way to modify a child's behavior.": This response is appropriate because it addresses the mother's concern about punishment for the child's behavior. It educates the mother about the ineffectiveness and potential harm of physical punishment in modifying behavior. Instead, positive reinforcement, redirection, and open communication are recommended strategies for guiding children's behavior.

C. "It isn't unusual for him to fondle his genitals, as this is part of his exploration of his body.": This response normalizes the child's behavior of touching and playing with his genitals as part of natural childhood development. It reassures the mother that such behavior is common and not necessarily indicative of abnormality or misconduct. Education about normal childhood sexual development can alleviate parental concerns and promote understanding and acceptance.

D. "Constantly touching the genitals indicates a urinary tract infection in a toddler.": This response is incorrect and may unnecessarily alarm the mother. While frequent touching of the genitals could indicate discomfort or irritation associated with a urinary tract infection in a toddler, it is not the case for a 7-year-old child. Additionally, it is essential to avoid making medical diagnoses without proper assessment by a healthcare professional.

E. "Give him a little time, and he'll grow out of it. He's just too young to understand right now." This response acknowledges the child's developmental stage and suggests that the behavior is likely temporary and will naturally resolve as the child matures. It reassures the mother that the behavior is typical for a child of this age and may not require immediate intervention.

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The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

A client, who is on bedrest after surgery, complains of feeling bloated and having continuous oozing of small amounts of liquid stool. The nurse recognizes this as being symptomatic of which condition?

Correct Answer is D

Explanation

The mother of a 7-year-old child is concerned that the child "touches and plays" with the genitals despite being punished for doing so. Which response should the nurse make to the mother? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","E"]

Explanation

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