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:
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.
Correct Answer is B
Explanation
Choice A: Physical therapist
Physical therapists primarily focus on improving a patient’s physical function, mobility, and strength. They work on activities such as walking, balance, and coordination1. While they play a crucial role in the rehabilitation of clients with traumatic brain injuries, their expertise is not specifically centered on activities of daily living (ADLs) like using eating utensils.
Choice B: Occupational therapist
Occupational therapists specialize in helping clients regain the ability to perform ADLs, which include tasks such as eating, dressing, and bathing. They use therapeutic techniques to improve fine motor skills, coordination, and cognitive function, which are essential for relearning how to use eating utensils. Their goal is to enhance the client’s independence and quality of life by enabling them to perform everyday activities.
Choice C: Speech-language pathologist
Speech-language pathologists focus on communication disorders and swallowing difficulties. They work with clients to improve speech, language, and cognitive-communication skills. While they are essential for addressing issues related to speech and swallowing, they do not typically focus on the motor skills required for using eating utensils.
Choice D: Social worker
Social workers provide support and resources to help clients and their families cope with the emotional, social, and financial aspects of a traumatic brain injury. They assist with discharge planning, accessing community resources, and providing counseling. However, they do not provide direct rehabilitation services related to the use of eating utensils.