A middle-aged adult client with nausea and vomiting for three days presents to the emergency room.
Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.
Increased heart rate.
Decreased blood pressure.
Increased temperature.
Hypoactive muscle responses.
Alert and oriented.
Correct Answer : A,B
Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.
Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.
Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.
Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.
Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:
- Heart rate: 60 to 100 beats per minute for adults
- Blood pressure: less than 120/80 mmHg for adults
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.
Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.
Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.
Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.
Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:
- Heart rate: 60 to 100 beats per minute for adults
- Blood pressure: less than 120/80 mmHg for adults
Correct Answer is A
Explanation
“Have you had thoughts about killing yourself?” This is the best response because it directly assesses the client’s suicidal risk and shows empathy and concern.
The other choices are wrong because:
Choice B. “What can’t you go on anymore?” This is a vague and open-ended question that does not address the client’s immediate safety or emotional state.
Choice C. “Don’t think like that.
It’s not true!” This is a dismissive and invalidating response that does not acknowledge the client’s feelings or offer support.
Choice D. “Have you talked to your doctor about these feelings?” This is a deferring and avoiding response that does not explore the client’s situation or provide any intervention.
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