A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

Distended neck veins

Postural hypotension

Dependent edema

Bradycardia

Answer and Explanation

The Correct Answer is B

A.   Extracellular fluid volume deficit (dehydration) typically leads to decreased venous return and reduced preload, resulting in flat or collapsed neck veins, rather than distended ones.
B.   In extracellular fluid volume deficit, there is a decrease in blood volume, which can result in postural hypotension when the client changes positions, due to inadequate fluid volume to maintain blood pressure.
C.   Extracellular fluid volume deficit is characterized by decreased fluid volume, which leads to decreased tissue perfusion and fluid shifts out of the interstitial spaces, resulting in reduced or absent edema.
D.   Bradycardia is not typically associated with extracellular fluid volume deficit.

Instead, tachycardia may occur as a compensatory mechanism to maintain cardiac output in response to decreased blood volume.

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Correct Answer is A

Explanation

A. Using a straw can increase the risk of aspiration for clients with dysphagia; thickened liquids should be consumed from a cup.
B. Taking breaks during meals can aid in swallowing and reduce the risk of aspiration.
C. Elevating the head of the bed to 90° helps prevent aspiration during swallowing.

D. Tucking the chin can help close off the airway during swallowing, reducing the risk of aspiration.

A. Pupils that are 8 to 9 mm in diameter B. Eyelids that blink involuntarily 30 to 35 times per minute C. Eyelashes that curl slightly outward. D. Corneas with an opaque appearance

Correct Answer is C

Explanation

A. Pupil size can vary but is typically around 3 to 5 mm in diameter under normal conditions.
B. The normal rate of involuntary blinking (spontaneous blinking) is approximately 15 to 20 times per minute.
C. Outwardly curling eyelashes are a normal anatomical variation and do not indicate any pathology.

D. Corneas should appear clear and transparent under normal conditions. Opacity of the cornea can indicate various eye disorders.

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A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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