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 D
Explanation
Choice A reason:
“It is not necessary to tell the doctor about the herbal supplements I take.” This statement is incorrect. It is crucial to inform the doctor about all medications, including herbal supplements, as they can interact with prescription medications and cause adverse effects. Herbal supplements can strongly affect the body and may not work well with prescription medicines.
Choice B reason:
“I am less likely to experience an allergic reaction from medications I have taken before.” This statement is incorrect. Allergic reactions can occur even if the medication has been taken before without any issues. The immune system can develop sensitivities over time, and an allergic reaction can happen at any point.
Choice C reason:
“If a medication makes me feel nauseated, then I should stop taking it for 1 week.” This statement is incorrect. Stopping a medication without consulting a healthcare provider can be dangerous. It is important to discuss any side effects with a healthcare provider to determine the best course of action. Stopping a medication abruptly can lead to worsening of the condition or other complications.
Choice D reason:
“My medications could interact with foods that I eat.” This statement is correct. Certain foods can interact with medications and affect their absorption, effectiveness, or cause adverse effects. For example, grapefruit juice can interact with statins and increase the risk of side effects. It is important to be aware of potential food-drug interactions and follow the healthcare provider’s advice on medication administration.
Correct Answer is D
Explanation
Choice A Reason:
The National League for Nursing (NLN) is an organization that focuses on nursing education and the development of nurse educators. While it plays a significant role in advancing the quality of nursing education, it does not define the nursing scope of practice. The NLN provides resources, professional development, and accreditation for nursing programs, but the legal scope of practice is determined by state laws and regulations.
Choice B Reason:
The Joint Commission is an independent, non-profit organization that accredits and certifies healthcare organizations and programs in the United States. Its primary role is to ensure that healthcare organizations meet certain performance standards to provide safe and effective care. While the Joint Commission sets standards for healthcare quality and safety, it does not define the nursing scope of practice. Its focus is on organizational accreditation rather than individual professional practice.
Choice C Reason:
The Patients Bill of Rights is a document that outlines the rights and responsibilities of patients within the healthcare system. It aims to ensure that patients receive fair and respectful treatment and have a voice in their care decisions. Although it is important for protecting patient rights, it does not define the nursing scope of practice. The Patients Bill of Rights addresses patient care from a consumer perspective rather than a professional regulatory standpoint.
Choice D Reason:
State-based Nurse Practice Acts are laws enacted by state legislatures that define the scope of practice for nurses within that state. These acts outline the legal parameters for nursing practice, including what tasks and responsibilities nurses are authorized to perform. They are designed to protect public health and safety by ensuring that nurses provide care within their level of competence and training. The Nurse Practice Acts are the primary source for defining the nursing scope of practice and are enforced by state boards of nursing.