A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?
Decreased bowel sounds.
Bilateral muscle weakness.
Thready pulse.
Distended neck veins
The Correct Answer is D
Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.
Choice A is wrong because decreased bowel sounds are not related to fluid volume excess.
Decreased bowel sounds can indicate ileus, obstruction, or peritonitis. Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess.
Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.
Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess.
Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Methimazole is an antithyroid medication that blocks the thyroid from making thyroid hormones. It is used to treat hyperthyroidism caused by Graves’ disease, which is an autoimmune disorder that stimulates the thyroid gland to produce excess hormones. After taking methimazole for 2 months, the client should expect to see a reduction in the symptoms of hyperthyroidism, such as weight loss, increased pulse rate, and heat intolerance. Increased sleeping is a sign of improved thyroid function, as hyperthyroidism can cause insomnia and restlessness.
Choice A is wrong because weight loss is a symptom of hyperthyroidism, not a result of methimazole treatment. Methimazole should lower the thyroid hormone levels and help the client gain weight.
Choice B is wrong because an increase in pulse rate is also a symptom of hyperthyroidism, not a result of methimazole treatment. Methimazole should lower the heart rate and blood pressure by reducing thyroid hormone levels.
Choice D is wrong because warmer skin is another symptom of hyperthyroidism, not a result of methimazole treatment. Methimazole should improve the client’s heat tolerance and make the skin cooler and less sweaty.
Correct Answer is A
Explanation
Hyponatremia is a condition where the sodium level in the blood is too low, which can cause confusion, lethargy, seizures, and coma. A hypertonic solution is a fluid that has a higher concentration of solutes than the blood, which can help raise the sodium level and reduce the brain swelling caused by hyponatremia. Therefore, improved cognition indicates that the treatment is effective.
Choice B. Cardiac arrhythmias absent.
Cardiac arrhythmias are not a common symptom of hyponatremia unless it is severe or rapid in onset.
Therefore, their absence does not necessarily indicate that the treatment is effective.
Choice C. Decreased vomiting.
Vomiting can be a cause or a consequence of hyponatremia, depending on the underlying condition.
Decreased vomiting may indicate that the patient is less nauseated, but it does not reflect the sodium level or the brain status.
Choice D. Absent Chvostek’s sign.
Chvostek’s sign is a facial twitching that occurs when tapping on the cheek, which indicates hypocalcemia (low calcium level).
It is not related to hyponatremia or hypertonic solution.
Normal ranges for sodium are 135 to 145 mEq/L and for calcium are 8.5 to 10.5 mg/dL.
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