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: I use garlic for my menopausal symptoms.
Garlic is not typically used for menopausal symptoms. Common herbal supplements for menopause include black cohosh, red clover, and evening primrose oil. These herbs are known to help alleviate symptoms such as hot flashes and night sweats. Garlic, on the other hand, is more commonly associated with cardiovascular benefits, such as lowering blood pressure and cholesterol levels.
Choice B: I use ginger when I get car sick.
Ginger is well-known for its effectiveness in treating nausea and motion sickness. Studies have shown that ginger can help reduce symptoms of motion sickness, such as dizziness, vomiting, and cold sweats. It works by stabilizing digestive function and maintaining consistent blood pressure, which helps alleviate nausea. Therefore, using ginger for car sickness is a correct and effective use of the supplement.
Choice C: I take ginkgo biloba for a headache.
Ginkgo biloba is not typically used for headaches. It is more commonly used to improve cognitive function and circulation. While some studies suggest that ginkgo biloba may help reduce the frequency and severity of migraines due to its antioxidant properties, it is not a primary treatment for headaches. Other supplements, such as feverfew and butterbur, are more commonly recommended for headache relief.
Choice D: I take echinacea to control my cholesterol.
Echinacea is primarily used to boost the immune system and help fight infections, such as the common cold. There is no substantial evidence to support the use of echinacea for controlling cholesterol levels For cholesterol management, supplements like omega-3 fatty acids, plant sterols, and soluble fiber are more effective.
Correct Answer is A
Explanation
Choice A reason:
A client who has new onset of dyspnea 24 hours after a total hip arthroplasty should be seen first. Dyspnea, or difficulty breathing, can be a sign of a serious complication such as a pulmonary embolism, which is a medical emergency. Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. This condition requires immediate assessment and intervention to prevent life-threatening consequences.
Choice B reason:
A client who has a urinary tract infection and low-grade fever is a concern, but it is not as urgent as the client with new onset dyspnea. Urinary tract infections (UTIs) are common and can be managed with antibiotics and supportive care. While a low-grade fever indicates an infection, it does not pose an immediate threat to the client’s life. The nurse should still address this client’s needs, but it can be done after attending to the more urgent case.
Choice C reason:
A client who has acute abdominal pain of 4 on a scale from 0 to 10 should be assessed, but it is not as critical as the client with new onset dyspnea. Acute abdominal pain can have various causes, some of which may require urgent attention, but a pain level of 4 indicates moderate pain. The nurse should evaluate this client to determine the cause of the pain and provide appropriate interventions, but it can be done after addressing the more urgent case.
Choice D reason:
A client who has pneumonia and an oxygen saturation of 96% is stable at the moment. Oxygen saturation levels above 95% are generally considered acceptable in pneumonia patients. While pneumonia requires monitoring and treatment, the client’s current oxygen saturation level indicates that they are not in immediate respiratory distress. The nurse should continue to monitor this client and provide necessary care, but it can be done after attending to the more urgent case.
