A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)
Increased respiratory rate.
Increased heart rate
Increased blood pressure
Increased Hematocrit
Increased temperature
Correct Answer : A,B,C
Choice A: Increased Respiratory Rate
Fluid overload, also known as hypervolemia, can lead to an increased respiratory rate. This occurs because the excess fluid in the body can accumulate in the lungs, leading to pulmonary congestion and edema. As a result, the body attempts to compensate by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide. Normal respiratory rate for adults is typically between 12-20 breaths per minute. An increased respiratory rate above this range can indicate fluid overload.
Choice B: Increased Heart Rate
An increased heart rate, or tachycardia, is another common finding in clients with fluid overload. The heart has to work harder to pump the excess fluid throughout the body, leading to an increased heart rate. This is a compensatory mechanism to maintain adequate cardiac output and tissue perfusion. Normal resting heart rate for adults is between 60-100 beats per minute. A heart rate above this range can be indicative of fluid overload.
Choice C: Increased Blood Pressure
Fluid overload can also result in increased blood pressure, or hypertension. The excess fluid in the bloodstream increases the volume of blood that the heart has to pump, leading to higher pressure within the arteries. This can strain the cardiovascular system and lead to complications if not managed properly. Normal blood pressure is typically around 120/80 mmHg. Blood pressure readings consistently above this range can suggest fluid overload.
Choice D: Increased Hematocrit
Increased hematocrit is not typically associated with fluid overload. Hematocrit is the proportion of red blood cells in the blood. In cases of fluid overload, the hematocrit level is usually decreased due to the dilutional effect of the excess fluid. Therefore, this choice is incorrect.
Choice E: Increased Temperature
Increased temperature is not a common finding in fluid overload. Fever or elevated body temperature is more commonly associated with infections or inflammatory conditions. Fluid overload does not typically cause an increase in body temperature. Therefore, this choice is incorrect.
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Correct Answer is D
Explanation
Choice A Reason:
Pronation of the hands is not typically associated with decorticate posturing. Decorticate posturing is characterized by the flexion of the arms and wrists, with the hands often clenched into fists. Pronation refers to the rotation of the hands so that the palms face downward, which is not a feature of decorticate posturing.
Choice B Reason:
Extension of the arms is more characteristic of decerebrate posturing, not decorticate posturing. In decorticate posturing, the arms are flexed and held tightly to the chest, not extended. This flexion is due to damage to the cerebral hemispheres, which affects the corticospinal tract.
Choice C Reason:
External rotation of the lower extremities is not a typical finding in decorticate posturing. In decorticate posturing, the legs are usually
extended and rigid, with the toes pointed. External rotation would indicate a different type of posturing or neurological condition.
Choice D Reason:
Plantar flexion of the legs is a characteristic finding in decorticate posturing. This involves the toes pointing downward, which is a result of the increased muscle tone and reflexes due to the brain injury. This posture indicates severe damage to the brain, specifically the corticospinal tract.
Correct Answer is B
Explanation
Choice A Reason:
Decrease protein intake: This is not typically recommended for clients with Cushing’s disease. Protein is essential for maintaining muscle mass and overall health. Clients with Cushing’s disease often experience muscle weakness and wasting, so adequate protein intake is crucial to help counteract these effects. Therefore, decreasing protein intake would not be beneficial.
Choice B Reason:
Restrict sodium intake: Clients with Cushing’s disease often suffer from hypertension (high blood pressure) due to the excess cortisol in their bodies. High sodium intake can exacerbate this condition by increasing blood pressure even further. Therefore, it is crucial to restrict sodium intake to help manage hypertension and reduce the risk of cardiovascular complications. Foods high in sodium include processed foods, canned soups, and salty snacks. The recommended daily sodium intake for most adults is less than 2,300 milligrams, but for those with hypertension, it is often advised to consume even less.
Choice C Reason:
Limit intake of potassium-rich foods: This is not a standard recommendation for clients with Cushing’s disease. In fact, potassium is often beneficial as it can help counteract the effects of sodium and lower blood pressure. Potassium-rich foods include bananas, oranges, spinach, and sweet potatoes. Limiting these foods would not be advantageous and could potentially worsen hypertension.
Choice D Reason:
Increase carbohydrate intake: Increasing carbohydrate intake is not typically recommended for clients with Cushing’s disease. Excess cortisol can lead to increased blood sugar levels and a higher risk of developing diabetes. Therefore, it is important to manage carbohydrate intake carefully to avoid spikes in blood sugar. Instead, a balanced diet with a focus on complex carbohydrates, lean proteins, and healthy fats is recommended.
