A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)
Pale yellow urine
Bradycardia
Poor skin turgor
Flat neck veins
Hypotension
Correct Answer : C,D,E
A. In cases of dehydration, urine output may decrease, resulting in a more concentrated urine that appears darker in color. Therefore, the nurse may expect the urine to be darker in color.
B. Tachycardia is more commonly observed due to dehydration and the body's compensatory mechanisms.
C. Poor skin turgor is a classic sign of dehydration and may be observed in clients with vomiting and diarrhea.
D. Flat neck veins are typically associated with dehydration. This occurs due to reduced intravascular volume leading to collapse of the veins.
E. Hypotension is commonly associated with dehydration resulting from vomiting and diarrhea. Loss of fluids and electrolytes can lead to decreased blood volume and subsequent hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Providing toys or drawing materials can help the child express their thoughts, feelings, and experiences in a nonverbal and developmentally appropriate manner. Play-based activities allow children to communicate and process their emotions more comfortably than verbal communication alone.
A. For young children, especially those who have experienced trauma, the presence of a caregiver can provide comfort, reassurance, and support during the assessment process.
C. Neglecting the child's emotional needs can result in overlooking important aspects of their experience and hinder their recovery.
D. Asking the child to repeat the events of the trauma can be retraumatizing and overwhelming for them.
Correct Answer is ["A","B","C","D","E"]
Explanation
Supporting the client's rituals can provide comfort and dignity during this challenging time. It honors their preferences and cultural or religious beliefs, contributing to their overall well-being.
Having loved ones present can offer emotional support to both the client and their family members during the withdrawal of MANH. It allows for meaningful connections and facilitates closure.
Providing mouth sponges with preferred flavors can help alleviate dryness and discomfort in the oral cavity that may occur after the withdrawal of MANH. It promotes comfort and enhances the client's quality of life.
Spiritual support can be valuable for clients and their families during the end-of-life process. If the client desires spiritual guidance or support, arranging for a visit from a spiritual advisor can address their spiritual needs and provide comfort.
Suctioning the oral cavity for pooling secretions can help maintain the client's comfort and prevent aspiration, particularly if the client is unable to swallow effectively. It supports respiratory hygiene and comfort.
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