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:
Going to bed at a different time each night can disrupt the body’s natural circadian rhythm, leading to poor sleep quality and increased stress levels. Consistent sleep schedules are crucial for maintaining good sleep hygiene and reducing stress. Regular sleep patterns help regulate the body’s internal clock, improve sleep quality, and enhance overall well-being.
Choice B Reason:
Attending a support group each week can provide emotional support, reduce feelings of isolation, and offer practical advice for managing stress. Support groups create a sense of community and belonging, which can be very beneficial for mental health. Sharing experiences and coping strategies with others who are going through similar situations can help individuals feel understood and supported.
Choice C Reason:
Doing tasks oneself rather than delegating can lead to increased stress and burnout, especially if the workload is overwhelming. Effective stress management includes recognizing when to delegate tasks to others. Delegation helps distribute the workload, prevents burnout, and allows individuals to focus on more critical tasks. It also fosters teamwork and collaboration.
Choice D Reason:
Exercising for 1 hour each week is beneficial, but it may not be sufficient for effective stress management. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous activity per week for optimal health benefits. Regular physical activity helps reduce stress, improve mood, and enhance overall physical and mental health.
Correct Answer is A
Explanation
Choice A Reason
Waiting 5 minutes between the administration of each medication is the most appropriate action. This allows each medication to be absorbed properly without being washed away by the subsequent drops. Adequate absorption ensures that each medication can exert its therapeutic effect effectively.
Choice B Reason
Asking the client to close their eyes tightly after instilling each medication is not recommended. This action can force the medication out of the eye, reducing its effectiveness. Instead, clients should be advised to close their eyes gently to allow the medication to spread evenly across the eye surface.
Choice C Reason
Holding the dropper 3 cm (1.2 in) away from the client’s eye is too far. The recommended distance is about 1 to 2 cm (0.4 to 0.8 in) to ensure that the drops are accurately placed in the conjunctival sac without touching the eye or eyelashes, which could cause contamination.
Choice D Reason
Massaging the client’s eyelids for 20 seconds after instillation is not a standard practice for administering ophthalmic drops. This action could potentially irritate the eye or cause discomfort. Instead, gentle pressure can be applied to the inner corner of the eye (nasolacrimal duct) for a few seconds to prevent the medication from draining into the tear duct.