A client is admitted to the medical unit with fluid volume overload due to heart failure. Clinical manifestations of this problem are [Select all that apply]:

Choice A reason: This statement is false. Edema is a sign of fluid overload, not fluid deficit. Edema occurs when fluid accumulates in the interstitial space due to increased capillary hydrostatic pressure or decreased plasma oncotic pressure. Edema is more common in patients with heart failure, liver disease, or kidney disease¹.

Choice B reason: This statement is false. Skin turgor is a measure of skin elasticity and hydration. It can be affected by factors such as age, skin condition, and ambient temperature. Skin turgor is not a reliable indicator of fluid balance, as it can be normal in patients with mild to moderate hypovolemia².

Choice C reason: This statement is false. Urine output is a measure of kidney function and fluid excretion. It can be influenced by factors such as fluid intake, diuretics, hormones, and renal diseases. Urine output is not a sensitive indicator of fluid balance, as it can be normal or even increased in patients with hypovolemia due to compensatory mechanisms.

Choice D reason: This statement is true. Daily weight is a measure of body mass and fluid status. It can reflect changes in fluid balance more accurately than other methods, as long as the weight is measured at the same time, on the same scale, and with the same clothing each day. A decrease in weight can indicate fluid loss due to hypovolemia.

Choice A reason: This statement is true. Distended neck veins are a sign of fluid volume overload, as they indicate increased central venous pressure and right-sided heart failure.

Choice B reason: This statement is false. Hypotension is a sign of fluid volume deficit, not fluid volume overload. Hypotension occurs when the blood pressure is too low to perfuse the vital organs.

Choice C reason: This statement is false. Increased serum osmolality is a sign of fluid volume deficit, not fluid volume overload. Increased serum osmolality occurs when the blood concentration of solutes, such as sodium and glucose, is too high due to fluid loss.

Choice D reason: This statement is false. Dry oral mucosa is a sign of fluid volume deficit, not fluid volume overload. Dry oral mucosa occurs when the oral cavity is dehydrated due to fluid loss.

Choice E reason: This statement is true. Decreased urine specific gravity is a sign of fluid volume overload, as it indicates diluted urine and impaired kidney function.

Choice F reason: This statement is true. Weight gain is a sign of fluid volume overload, as it indicates fluid retention and edema.

Choice G reason: This statement is false. Sunken anterior fontanelle is a sign of fluid volume deficit, not fluid volume overload. Sunken anterior fontanelle occurs when the soft spot on the baby's head is depressed due to fluid loss.