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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.)

A.

Pale yellow urine

B.

Poor skin turgor

C.

Hypotension

D.

Flat neck veins

E.

Bradycardia

Question Solution

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 B

Explanation

A. The planning phase involves setting goals and determining interventions based on the assessment data.

B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.

C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.

D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.

Correct Answer is B

Explanation

A. Pigeon chest (pectus carinatum) is a structural deformity of the chest and is not associated with COPD.

B. A barrel chest is commonly seen in clients with COPD due to hyperinflation of the lungs, causing the chest to appear rounded and expanded.

C. Kyphotic refers to an abnormal curvature of the spine (kyphosis) and is not a characteristic of COPD.

D. Funnel chest (pectus excavatum) is another structural deformity and is not typically associated with COPD.

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