A nurse is assessing an older adult client who has dysphagia and is experiencing dehydration. Which of the following findings should the nurse expect?
Tachycardia
Hypertension
Distended neck veins
Decreased respiratory rate
The Correct Answer is A
The expected finding in an older adult client with dysphagia and dehydration is tachycardia. Tachycardia, an increased heart rate, is a common finding in dehydration as the body tries to compensate for the decreased fluid volume.
The other choices (hypertension, distended neck veins, and decreased respiratory rate) are not typically associated with dehydration in this context.
here's an explanation of why these choices are incorrect:
1. Hypertension: Dehydration usually leads to a decrease in blood volume, resulting in low blood pressure rather than hypertension. Hypertension is not a typical finding in dehydration.
2. Distended neck veins: Dehydration causes a decrease in blood volume, which results in decreased venous return to the heart. Consequently, distended neck veins would not be an expected finding.
3. Decreased respiratory rate: Dehydration itself does not directly affect respiratory rate. However, severe dehydration can lead to electrolyte imbalances, such as hyponatremia (low sodium levels), which can affect brain function and potentially lead to changes in respiratory rate. However, decreased respiratory rate is not a common finding in dehydration alone.
It's important to remember that dehydration can have various signs and symptoms, including dry mucous membranes, decreased urine output, increased thirst, dry skin, dizziness, and confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should identify the statement "I like to drink a glass of warm milk before bed to help me sleep" as a contributing factor to gastroesophageal reflux disease (GERD). Consuming a glass of warm milk before bed can worsen GERD symptoms due to its high-fat content. High-fat foods, including dairy products, can relax the lower esophageal sphincter (LES) and delay gastric emptying, allowing stomach acid to flow back into the esophagus, leading to symptoms of GERD.
"I try to follow a low-fat, high-protein diet to help me maintain my weight": Following a low-fat, high-protein diet is actually beneficial for managing GERD. High-fat foods can worsen GERD symptoms by relaxing the LES and delaying gastric emptying, while a low-fat diet can help reduce symptoms.
"I stopped drinking caffeinated beverages several weeks ago": Avoiding caffeinated beverages is a positive step in managing GERD. Caffeine can stimulate acid production in the stomach and relax the LES, contributing to GERD symptoms.
"I have recently stopped drinking alcohol": Stopping alcohol consumption is also beneficial for managing GERD. Alcohol can relax the LES and increase acid production in the stomach, leading to GERD symptoms.
Correct Answer is C
Explanation
Dysphagia refers to difficulty or discomfort in swallowing. It can occur as a result of weakened or impaired muscles involved in swallowing, which is common after a stroke. When dysphagia is present, it can affect the function of the vocal cords and lead to changes in voice quality, including hoarseness. The hoarseness may be due to the entry of food or liquid into the airway during swallowing, causing irritation to the vocal cords.
Weight gain is not a typical manifestation of dysphagia. If dysphagia is severe and leads to food avoidance or restricted intake, weight loss may occur instead.
Continuous smiling is not a specific manifestation of dysphagia. It may be seen in some stroke survivors as a result of changes in facial muscle control, such as facial weakness or spasticity. However, it is not directly related to dysphagia.
Expressive aphasia refers to difficulty expressing thoughts or using language effectively. It is a common language impairment that can occur after a stroke, specifically affecting the ability to produce or articulate words and sentences. While it is a communication difficulty, it is not directly related to dysphagia, which specifically refers to difficulty swallowing.
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