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

Answer and Explanation

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.

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Correct Answer is A

Explanation

This is important because it allows the nurse to assess the client's ability to communicate in their primary language. Knowing the client's level of fluency helps the nurse determine the most effective communication strategies and whether an interpreter is necessary.

B. While nodding can be a form of nonverbal communication indicating understanding, relying solely on this may not accurately gauge the client's comprehension.

C. Even in the presence of n interpreter, the nurse should speak directly to the client.

D. Family members may not be proficient in both languages or may not accurately convey medical information.

A. Close friend B. Social worker C. Chaplain D. Psychologist

Correct Answer is A

Explanation

A Close friend may provide warm feeling of support due to their background knowledge of the client. It gives the client a sense of belonging and support.

B Social workers are trained to provide crisis intervention, advocacy, and support services tailored to the needs of survivors of sexual assault. However, thery might not be able to connect closely with the client like a close friend.
C. Chaplains may offer emotional and spiritual support to individuals in crisis situations, including survivors of sexual assault but are not trained to handle such cases.
D. While their expertise is valuable for long-term therapy and support, they may not be readily available for immediate crisis intervention in the emergency department.

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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.)

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