A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?
Edema
Oliguria
Hypotension
Hyperthemia
The Correct Answer is A
A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.
B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.
C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.
D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Chadwick's sign: Chadwick's sign is related to pregnancy and refers to the bluish discoloration of the cervix and vaginal walls due to increased blood flow. It is not associated with calcium levels or postoperative thyroidectomy.
B) Murphy's sign: Murphy's sign is used to diagnose gallbladder inflammation or cholecystitis. It involves palpation of the right upper quadrant of the abdomen and is not related to calcium levels or thyroid surgery.
C) Babinski's sign: Babinski's sign is a neurological reflex test used to assess the presence of upper motor neuron lesions. It is not associated with calcium levels or postoperative thyroidectomy.
D) Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, where tapping on the facial nerve causes twitching of the facial muscles. With the client's calcium level of 3 mg/dL, which is significantly low, Chvostek's sign would likely be positive, indicating hypocalcemia.
Correct Answer is D
Explanation
A) Speech Therapist: A speech therapist typically works with clients who have communication or swallowing disorders. While they may be involved in assessing and managing difficulties with swallowing, they are not the primary professionals for addressing issues related to hand function or fine motor skills, which are crucial for self-feeding in clients with rheumatoid arthritis.
B) Registered Dietician: A registered dietician is responsible for assessing and planning nutritional needs, which may include recommending dietary modifications for overall health and well-being. However, they do not specifically address the mechanical or functional aspects of eating, such as difficulties due to pain and hand deformities in rheumatoid arthritis.
C) Physical Therapist: Physical therapists focus on improving gross motor function, mobility, and physical strength. While they may help with general mobility and exercise plans to reduce pain and improve joint function, they are not specialists in the fine motor skills and adaptive strategies needed for activities of daily living, such as self-feeding.
D) Occupational Therapist: Occupational therapists specialize in helping clients regain and improve their ability to perform daily activities, particularly those involving fine motor skills. They are well-suited to address issues like pain management, joint protection techniques, and the use of adaptive equipment for self-feeding in clients with rheumatoid arthritis. They work on enhancing the client’s functional independence despite physical limitations.
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