A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?
Dependent edema
Distended neck veins
Postural hypotension
Bradycardia
The Correct Answer is C
Choice A reason:
Dependent edema is not typically associated with extracellular fluid volume deficit. Edema usually occurs due to fluid overload or conditions that cause fluid retention, such as heart failure or kidney disease. In the case of extracellular fluid volume deficit, the body is losing more fluid than it is taking in, which would not result in edema. Instead, symptoms like dry skin, dry mucous membranes, and decreased skin turgor are more common.
Choice B reason:
Distended neck veins are also not a common finding in extracellular fluid volume deficit. Distended neck veins are usually seen in conditions where there is fluid overload or increased pressure in the venous system, such as heart failure or superior vena cava syndrome. In extracellular fluid volume deficit, the body is experiencing a reduction in fluid volume, which would not cause distended neck veins.
Choice C reason:
Postural hypotension, also known as orthostatic hypotension, is a common finding in extracellular fluid volume deficit. This condition occurs when there is a significant drop in blood pressure upon standing, leading to dizziness or lightheadedness. It is caused by the reduced blood volume, which decreases the amount of blood returning to the heart and subsequently lowers blood pressure.
Choice D reason:
Bradycardia, or a slow heart rate, is not typically associated with extracellular fluid volume deficit. In fact, the opposite is more likely to occur. Tachycardia, or a fast heart rate, is a common compensatory mechanism in response to fluid volume deficit as the body attempts to maintain adequate blood flow and pressure. Therefore, bradycardia would not be an expected finding in this scenario.
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View Related questions
Correct Answer is B
Explanation
Choice A Reason:
Adjusting the head of the bed to 90° is a recommended practice for clients with dysphagia. This position helps facilitate swallowing and reduces the risk of aspiration by using gravity to assist the passage of food and liquids from the mouth to the stomach.
Choice B Reason:
Drinking thickened juice with a straw is not recommended for clients with dysphagia. Using a straw can increase the speed and force with which liquids enter the mouth, making it harder to control the swallow and increasing the risk of aspiration. Thickened liquids are designed to move more slowly, giving the client more control over swallowing, but using a straw negates this benefit.
Choice C Reason:
Taking frequent breaks while eating is a good practice for clients with dysphagia. It allows them to chew and swallow food thoroughly, reducing the risk of choking and aspiration. This practice also helps prevent fatigue, which can impair swallowing function.
Choice D Reason:
Tucking the chin when swallowing, also known as the chin-tuck maneuver, is a common technique used to help clients with dysphagia. This action helps protect the airway by narrowing the entrance to the larynx and directing the food or liquid down the esophagus.
Correct Answer is B
Explanation
Choice A Reason:
A family whose only child recently died due to cancer is experiencing a significant and traumatic loss. This type of loss is categorized as a situational loss because it is unexpected and not part of the normal life cycle. Situational losses are typically sudden and can cause profound grief and disruption in the family’s life. The death of a child is one of the most devastating events a family can endure, leading to intense emotional pain and a long grieving process.
Choice B Reason:
A family whose oldest child is moving away for college is experiencing a maturational loss. Maturational losses are those that occur as part of normal life transitions and developmental stages. These losses are anticipated and expected as individuals grow and progress through different phases of life. The transition of a child moving away for college is a common maturational loss, as it signifies a significant change in the family dynamic and the child’s development into adulthood.
Choice C Reason:
A family whose house was destroyed in a fire is dealing with a situational loss. This type of loss is unexpected and can have a severe impact on the family’s sense of security and stability. The destruction of a home involves not only the loss of physical property but also the emotional attachment and memories associated with the home. Recovering from such a loss requires significant emotional and practical adjustments.
Choice D Reason:
A family whose head of household lost their job is experiencing a situational loss. Job loss can lead to financial instability and stress, affecting the entire family’s well-being. This type of loss is not part of the normal developmental process and can create significant challenges for the family as they navigate the uncertainty and potential changes in their lifestyle.
