A nurse is assessing a client. Which of the following findings indicates a fluid volume deficit?

Pitting edema

Skin tenting

Elevated blood pressure

Dyspnea

Answer and Explanation

The Correct Answer is B

Rationale:

A. Pitting edema: Pitting edema typically indicates fluid volume excess, not deficit. It occurs when there is an accumulation of fluid in the interstitial spaces, causing swelling that leaves an indentation when pressed.

B. Skin tenting: Skin tenting is a common sign of fluid volume deficit, particularly dehydration. It occurs when the skin loses elasticity due to a lack of adequate hydration, causing the skin to remain "tented" when pinched.

C. Elevated blood pressure: Elevated blood pressure is more commonly associated with fluid volume excess, not deficit. Increased fluid volume can lead to higher blood pressure due to greater circulating volume and increased vascular resistance.

D. Dyspnea: Dyspnea, or difficulty breathing, is a symptom that can be caused by a variety of conditions, including fluid volume excess, especially in the case of pulmonary edema. It is not a direct indicator of fluid volume deficit.

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Correct Answer is B

Explanation

Rationale:

A. Apply a sequential compression device: A sequential compression device (SCD) is used to prevent deep vein thrombosis (DVT), not foot drop. It does not provide the necessary support for preventing foot drop, which results from muscle weakness or paralysis after a CVA.

B. Use padded splints: Padded splints help maintain the foot in a neutral position, which is essential in preventing foot drop. Foot drop occurs due to weakness of the dorsiflexor muscles, and splints can prevent the foot from falling into an abnormal position, reducing the risk of deformities.

C. Elevate the extremity above the heart: Elevating the extremity above the heart is typically done to reduce edema, not to prevent foot drop. While elevating the limb can help with swelling, it does not address the muscle weakness that causes foot drop in post-CVA patients.

D. Reposition the client every 2 hr: Repositioning the client every 2 hours is important for preventing pressure ulcers and promoting circulation. However, it is does not prevent foot drop, which requires targeted interventions such as splints or exercises to maintain proper foot positioning.

A. "Keep your elbow in a flexed position." B. "Remain in a side-lying position." C. "Place a firm pillow under your head." D. "Wear splints on your wrists."

Correct Answer is D

Explanation

Rationale:

A. "Keep your elbow in a flexed position." Keeping the elbow in a flexed position increases the risk of contractures, particularly in the case of upper body burns. The goal is to keep the joints extended to prevent the development of contractures.

B. "Remain in a side-lying position." A side-lying position is not ideal for preventing contractures in the upper body. The client should be positioned to minimize pressure on the burn areas and encourage joint mobility, often with the client in a supine or elevated position.

C. "Place a firm pillow under your head." Placing a firm pillow under the head might cause the neck to flex, which could lead to neck contractures. A proper head and neck alignment should be maintained to avoid such complications.

D. "Wear splints on your wrists." Wearing splints on the wrists helps to keep the joints in proper alignment and prevents contractures by maintaining wrist extension. This is an appropriate intervention for clients with upper body burns to promote healing and function.

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A nurse is assessing a client. Which of the following findings indicates a fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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