A nurse is caring for a client who presented with nausea and extreme fatigue.
Nurse's Notes: 0915- Client reports worsening nausea and fatigue, stating he feels lightheaded when standing.
Skin turgor is poor and mucous membranes appear dry.
Client denies any recent infections or changes in medication.
1130- The client appears increasingly lethargic and has difficulty maintaining focus.
He has not eaten or drank anything in the past 12 hours.
The client has an indwelling catheter which has drained 200 mL over the last 12 hours.
Glucose level is 81 mg/dL. Vital Signs at 0900: Temperature 36.8 C (98.2 F), Heart Rate 110/min, Respiratory Rate 21/min, Blood Pressure 90/60 mmHg, Oxygen Saturation 98 Vital Signs at 1200: Temperature 37.0 C (98.6 F), Heart Rate 115/min, Respiratory Rate 22/min, Blood Pressure 88/58 mmHg, Oxygen Saturation 98 Which condition is the client most likely experiencing?
Hypovolemic shock.
Septic shock.
Hyperglycemic hyperosmolar state.
Acute urinary tract infection.
The Correct Answer is A
Choice A rationale
Hypovolemic shock results from a significant decrease in intravascular volume, which is evidenced by the client's physical findings and vital signs. Poor skin turgor and dry mucous membranes indicate severe dehydration. The low blood pressure of 88/58 mmHg and tachycardia of 115/min are compensatory mechanisms for low cardiac output. The low urine output of 200 mL over 12 hours is well below the normal range of 30 mL/hour or 0.5 to 1.5 mL/kg/hour, confirming renal hypoperfusion.
Choice B rationale
Septic shock typically presents with signs of systemic infection, such as fever, which this client lacks with a temperature of 37.0 C. While hypotension and tachycardia occur in sepsis, the client specifically denies recent infections, making this less likely than simple volume depletion. Sepsis involves vasodilation and increased capillary permeability rather than the primary fluid loss suggested by the dry membranes and poor turgor. The lack of inflammatory markers or history of infection differentiates this from hypovolemia.
Choice C rationale
Hyperglycemic hyperosmolar state is characterized by extreme dehydration and very high blood glucose levels, usually exceeding 600 mg/dL. This client's glucose level is 81 mg/dL, which is within the normal fasting range of 70 to 99 mg/dL. While both conditions cause dehydration and lethargy, the absence of hyperglycemia completely rules out this metabolic complication of type 2 diabetes. The low blood pressure and high heart rate here are due to fluid loss rather than osmotic diuresis from sugar.
Choice D rationale
Acute urinary tract infection would typically present with symptoms such as dysuria, frequency, urgency, or cloudy urine. Systemic manifestations might include fever or flank pain. While the client has an indwelling catheter, which increases infection risk, the primary clinical picture is dominated by cardiovascular instability and severe volume depletion rather than localized or systemic infection. The low urine output of 16.7 mL/hour is a sign of prerenal failure due to hypovolemia rather than an obstructive or infectious process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Hydration is a critical intervention for tumor lysis syndrome and hypercalcemia, but it is not the primary management strategy for spinal cord compression. In the context of spinal cord compression, excessive fluid administration does not address the mechanical pressure exerted by the tumor on the neural structures. Management must focus on reducing inflammation and stabilizing the spine rather than fluid volume expansion. Hydration is used to flush metabolic byproducts through the kidneys in other oncological emergencies.
Choice B rationale
Bisphosphonates like zoledronic acid are the gold standard for managing malignancy associated hypercalcemia. These drugs inhibit osteoclast activity, which reduces the release of calcium from the bone into the extracellular fluid. Normal serum calcium ranges from 8.5 to 10.5 mg/dL. By slowing bone resorption, bisphosphonates help lower serum calcium levels and prevent skeletal related events. This intervention addresses the underlying scientific mechanism of excessive bone breakdown common in patients with metastatic bone disease.
Choice C rationale
High dose intravenous corticosteroids, such as dexamethasone, are administered immediately to patients with spinal cord compression. These medications act as potent anti inflammatory agents that reduce vasogenic edema within the spinal cord and the surrounding tissues. By decreasing the swelling and the size of the inflammatory response around the tumor, steroids help alleviate pressure on the nerves, potentially preventing permanent paralysis. This is an essential emergency intervention to preserve motor and sensory function.
Choice D rationale
Placing the client in a semi-Fowler's position or maintaining proper body alignment helps optimize venous return and reduce the pressure exerted on the spinal column. This positioning can assist in minimizing discomfort and may help reduce the gravitational pressure on the site of the compression. In addition to pharmacological management, nursing care must include careful positioning to prevent further mechanical injury to the compromised cord while awaiting definitive treatment like radiation or surgical decompression.
Choice E rationale
Tumor lysis syndrome results in the rapid release of intracellular contents, including potassium, phosphorus, and nucleic acids, which are metabolized into uric acid. High fluid intake, often 3 L or more daily, is necessary to maintain high urine output and prevent the precipitation of uric acid crystals in the renal tubules. Aggressive hydration promotes the excretion of these electrolytes and toxins, thereby protecting the kidneys from acute renal failure during intensive chemotherapy or radiation.
Choice F rationale
While corticosteroids are useful in managing hypercalcemia associated with certain hematological malignancies like lymphoma or multiple myeloma, they are not the primary high dose IV treatment for all cases of hypercalcemia. Bisphosphonates and aggressive hydration are more universal first line treatments. In the case of spinal cord compression, corticosteroids are used to reduce edema, but their role in general hypercalcemia management is more limited and specific to the type of tumor causing the calcium elevation.
Choice G rationale
Blood cultures are diagnostic tools used to identify systemic infections or sepsis by detecting pathogens in the bloodstream. Hypercalcemia is a metabolic derangement characterized by elevated serum calcium levels and is not typically caused by an acute infection that would be identified through blood cultures. While a patient with hypercalcemia could also have an infection, obtaining blood cultures is not a standard or appropriate intervention for the direct management of elevated calcium levels. .
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
This statement is incorrect because hot, dry skin is a hallmark characteristic of heat stroke rather than heat exhaustion. In heat stroke, the body's thermoregulatory mechanisms fail entirely, and the person stops sweating, leading to a dangerous rise in core body temperature, often exceeding 104 degrees Fahrenheit or 40 degrees Celsius. In contrast, patients experiencing heat exhaustion are typically still able to sweat profusely as their body attempts to dissipate heat through the process of evaporation.
Choice B rationale
Heat exhaustion often involves hypotension and tachycardia as the body attempts to compensate for significant fluid and electrolyte loss. Excessive sweating leads to a decrease in intravascular volume, which lowers blood pressure. The heart rate increases as a compensatory mechanism to maintain cardiac output and perfusion to vital organs. These clinical findings are essential for differentiating exhaustion from simpler heat cramps. Understanding these hemodynamics helps the nurse prioritize fluid resuscitation to prevent the progression to life-threatening heat stroke.
Choice C rationale
Altered mental status, confusion, seizures, or coma are definitive characteristics of heat stroke that distinguish it from heat exhaustion. As the core body temperature rises to critical levels, the central nervous system becomes impaired due to thermal injury and cerebral edema. While a person with heat exhaustion may feel weak or dizzy, they generally remain cognitively intact. The presence of neurological dysfunction signifies a medical emergency requiring immediate and aggressive cooling measures to prevent permanent brain damage or multi-organ failure.
Choice D rationale
Excessive sweating and clammy, pale skin are classic signs of heat exhaustion. During this stage, the thermoregulatory system is still functioning but is overwhelmed by the heat load and fluid depletion. The skin feels cool and moist because the body is still pushing blood to the periphery to encourage cooling through sweat. Normal lab parameters for sodium are 135 to 145 mEq/L, and these levels can fluctuate significantly during heat-related illnesses, requiring careful monitoring and replacement during treatment. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.