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 D
Explanation
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B. Fremitus is related to lung assessment and is not a manifestation of rheumatoid arthritis.
C. Tenderness in the soles of the feet is not a classic early manifestation of RA.
D. Joint swelling is one of the hallmark early signs of rheumatoid arthritis due to inflammation of the synovial membranes.
Correct Answer is ["A","B","D","E"]
Explanation
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.