A nurse is assessing a client who reports taking a medication that causes increased urination resulting in dehydration for the past 3 days. Which findings should the nurse expect in a client who is dehydrated? (Select all that apply.)
Pale yellow urine
Poor skin turgor
Hypotension
Flat neck veins
Bradycardia
Correct Answer : B,C,D
A. Pale yellow urine is typically associated with good hydration; dehydration would likely result in darker urine.
B. Poor skin turgor is a classic sign of dehydration, indicating a lack of adequate fluid in the tissues.
C. Hypotension (low blood pressure) can occur with dehydration due to decreased blood volume.
D. Flat neck veins may indicate a decrease in venous return due to low blood volume associated with dehydration.
E. Bradycardia (slow heart rate) is not typically a finding associated with dehydration; instead, dehydration often leads to tachycardia (increased heart rate) as the body attempts to compensate for low blood volume.
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Correct Answer is ["A","C"]
Explanation
A. Increase daily exercise: Regular physical activity helps stimulate bowel movements and can relieve constipation.
B. Be sure to take good care of your teeth: While dental health is important, it is not directly related to constipation management.
C. Incorporate more fresh fruits and vegetables in your daily intake: These foods are high in fiber, which helps to soften stool and promote regularity.
D. Avoid drinking hot liquids: This is not a standard recommendation for managing constipation; warm liquids can sometimes aid in bowel movements.
E. Increase intake of low fiber foods: This would likely worsen constipation, as low-fiber diets can contribute to harder stools.
Correct Answer is C
Explanation
A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.
B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.
C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.
D. Grimacing is an objective observation by the nurse, not a subjective report from the client.