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 D
Explanation
Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.
Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.
Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.
Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.
Correct Answer is C
Explanation
This is because immobilizing the wrist prevents kinking or dislodgement of the intravenous catheter and reduces the risk of complications such as infiltration, phlebitis, or infection.
Some additional information for the response are:
Choice A is wrong because placing the arm across the client’s chest may compromise venous return and increase the risk of thrombosis.
Choice B is wrong because using a wrist restraint may cause skin breakdown, nerve damage, or impaired circulation.
Choice D is wrong because instructing the client to limit use the of that arm may not be sufficient to prevent catheter movement or accidental removal.
Normal ranges for venous access depend on the type and location of the catheter, but some general values are: potassium (3 to 5 mEq/L), blood urea nitrogen (10 to 20 mg/dL), and central venous pressure (8 to 12 mmHg).
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