A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?
Oliguria
Hypertension
Bradycardia
Peripheral edema
The Correct Answer is A
A. Oliguria, or decreased urine output, is a common finding in hypovolemia due to reduced renal perfusion and decreased blood flow to the kidneys.
B. Hypertension is unlikely in hypovolemia; instead, clients typically exhibit hypotension due to decreased circulating blood volume.
C. Bradycardia is not a typical finding in hypovolemia; instead, tachycardia is more commonly observed as the body compensates for reduced blood volume.
D. Peripheral edema is associated with fluid overload rather than hypovolemia, as a decrease in blood volume usually leads to less fluid accumulation in the tissues.
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Correct Answer is D
Explanation
A. Muscle weakness and confusion are more commonly associated with metabolic or mixed acid-base disturbances rather than respiratory alkalosis specifically.
B. Decreased deep tendon reflexes and hypotension are not typical signs of respiratory alkalosis, which usually involves changes in breathing patterns.
C. Bradycardia and decreased respiratory rate are more likely associated with respiratory acidosis or other conditions, not with respiratory alkalosis.
D. Rapid, shallow breathing, often due to anxiety or panic attacks, is characteristic of respiratory alkalosis. Patients may also report feelings of panic due to the hyperventilation that leads to this condition.
Correct Answer is A
Explanation
A. Stridor is a high-pitched sound indicating upper airway obstruction and is a critical sign of anaphylaxis requiring immediate intervention to secure the airway.
B. Hypotension is a serious condition that occurs during anaphylaxis, but the priority is to address the airway obstruction first.
C. Urticaria (hives) is a common symptom of an allergic reaction but is not life-threatening and can be addressed after more severe symptoms.
D. Vomiting may occur during anaphylaxis but is not the most urgent finding when airway compromise is present.