A nurse is assessing a client who is experiencing hypovolemia.
Which of the following manifestations should the nurse expect
Epistaxis
Headache
Dizziness
Shortness of breath
The Correct Answer is C
, dizziness.
Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss.
Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.
Choice A, epistaxis, is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.
Choice B, headache, is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.
Choice D, shortness of breath, is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.
Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults.
Normal ranges for heart rate are 60 to 100 beats per minute for adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications.
Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
Choice D is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications.
Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).
Correct Answer is B
Explanation
The correct answer is choice B. Wear clean cotton socks every day.
This is because cotton socks can help keep the feet dry and prevent infections. Wearing clean socks every day can also prevent blisters and injuries from friction.
Choice A is wrong because soaking feet twice daily can make the skin too soft and prone to injury. It can also wash away natural oils that protect the skin.
Choice C is wrong because rounding the edges of toenails when trimming can cause ingrown nails, which can lead to infection and pain. Toenails should be trimmed straight across and filed smooth.
Choice D is wrong because using moisturizing lotion between the toes can create a moist environment that promotes fungal growth. Moisturizing lotion should be applied to the rest of the feet, but not between the toes.
Some other foot care guidelines for people with diabetes are:
- Inspect your feet daily and look for signs of injury, such as scrapes, cuts, blisters, etc.
- Wash your feet every day in warm water with mild soap.
Hot water and harsh soaps can damage your skin. Check the water temperature with your fingers or elbow before putting your feet in.
- Don’t walk barefoot.
Protect your feet from heat and cold. Wear appropriate fitting shoes to avoid injury and blisters.
- See a doctor to remove corns or calluses (don’t do it yourself). Don’t use chemical wart removers, razor blades, corn plasters, or liquid corn or callus removers.
- Don’t sit with your legs crossed or stand in one position for long periods of time.
- See your doctor regularly for foot exams and report any problems or changes in your feet.
References:
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