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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Correct Answer is C
Explanation
Choice A reason:
Preventive care focuses on measures taken to prevent diseases, rather than treating them. This includes vaccinations, screenings, and lifestyle counseling. Emergency care, which deals with immediate and acute medical conditions, does not fall under preventive care. Preventive care aims to reduce the incidence of diseases and conditions before they occur, whereas emergency care addresses urgent health issues that require immediate attention.
Choice B reason:
Tertiary care involves specialized consultative care, usually on referral from primary or secondary medical care personnel. It includes advanced medical investigation and treatment, such as cancer management, neurosurgery, cardiac surgery, and other complex medical and surgical interventions. Emergency care, which provides immediate treatment for acute illnesses and injuries, is not categorized under tertiary care. Tertiary care is more about long-term and specialized treatment.
Choice C reason:
Primary care is the first point of contact for individuals entering the healthcare system. It includes general health care services provided by physicians, nurse practitioners, and physician assistants. Primary care focuses on overall health maintenance, disease prevention, and the treatment of common illnesses and conditions. Emergency care, which deals with acute and urgent medical conditions, is not part of primary care. Primary care providers may refer patients to emergency care when immediate attention is needed.
Choice D reason:
Secondary care involves specialized medical services provided by specialists after referral from a primary care provider. It includes services such as cardiology, dermatology, and orthopedics. Emergency care, which provides immediate treatment for acute medical conditions, is considered part of secondary care. Emergency departments in hospitals are staffed by specialists who provide urgent and critical care to patients.
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.