A nurse is admitting a client who reports persistent nausea, vomiting, and weakness for three days. The client has dry oral mucous membranes, weak peripheral pulses, and decreased skin turgor. What additional assessment findings should the nurse identify as manifestations related to the fluid imbalance? (Select All That Apply)
Muscle cramps
Bradycardia
Concentrated urine
Tachycardia
Increased thirst
Correct Answer : A,C,D,E
A. Muscle cramps: Muscle cramps can occur due to electrolyte imbalances, such as low potassium, which are common in states of dehydration and fluid imbalance.
B. Bradycardia: Bradycardia is not typically associated with dehydration or fluid imbalance. Dehydration usually causes an increase in heart rate (tachycardia) as the body tries to maintain adequate circulation.
C. Concentrated urine: Concentrated urine is a common sign of dehydration as the kidneys conserve water, leading to reduced urine output and higher urine concentration.
D. Tachycardia: Tachycardia is a compensatory mechanism in response to decreased fluid volume, as the heart pumps faster to maintain adequate blood flow and blood pressure.
E. Increased thirst: Increased thirst is a natural response to dehydration as the body signals the need for more fluid intake to correct the fluid imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will increase my fluid and fiber intake while I am taking iron tablets.": This statement is correct as increasing fluid and fiber can help manage constipation, a common side effect of iron supplementation.
B. "I will take the tablets with water an hour before eating.": This is correct because taking iron supplements on an empty stomach can improve absorption, and water helps dissolve the tablets.
C. "I will immediately call my health care provider if my stools turn green.": This statement indicates a misunderstanding, as green stools are a common and harmless side effect of iron supplements. They are not typically a cause for concern unless accompanied by other symptoms.
D. "I will take a stool softener if I occasionally feel constipated.": This is a correct and appropriate approach, as stool softeners can help alleviate constipation caused by iron supplements.
Correct Answer is C
Explanation
A. Imitation of the lining of the stomach: This is not a common complication related to calcium supplementation or fluid intake.
B. Mobilization of calcium from bones: Drinking fluids does not affect the mobilization of calcium from bones; this is more related to bone health and calcium metabolism.
C. Developing kidney stones: Adequate fluid intake helps prevent kidney stones, which can form when there is excess calcium in the urine. High calcium levels can lead to stone formation if not properly managed with sufficient hydration.
D. Developing muscle cramps: While calcium plays a role in muscle function, fluid intake primarily helps with kidney function and preventing stone formation rather than directly preventing muscle cramps.
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