A nurse is caring for an older adult client. The nurse suspects that the client may be experiencing hypovolemia. For which clinical indicators should the nurse assess the dient that supports this conclusion? (Select All That Apply)
Amber/dark colored urine
Weak, thready pulse
Distended neck veins
Bradycardia
Decreased capillary refill
Correct Answer : A,B,E
A. Amber or dark-colored urine is a sign of dehydration and indicates a decrease in fluid volume.
B. A weak, thready pulse is often seen in clients with hypovolemia due to reduced circulating blood volume.
C. Distended neck veins are a sign of fluid overload, not hypovolemia.
D. Bradycardia is typically not associated with hypovolemia; tachycardia is more common.
E. Decreased capillary refill is indicative of reduced perfusion, a symptom of hypovolemia.
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Related Questions
Correct Answer is D
Explanation
A. The dorsal surface of the hand is used for assessing temperature, not palpation.
B. The fingertips and palmar surface are used for deep palpation, not light palpation.
C. The palmar surface of the fingers can be used, but the finger pads provide more sensitivity for light palpation, especially when assessing the abdomen.
D. Finger pads are the best part of the hand for light palpation as they allow the nurse to assess tenderness and abdominal consistency accurately.
Correct Answer is B
Explanation
A. Having the client place a plastic bag over their head is dangerous and should never be done.
B. Teaching breathing techniques, such as diaphragmatic breathing or using a paper bag, helps the client retain more carbon dioxide and can prevent respiratory alkalosis.
C. Positioning the client in a high-Fowler position may be helpful for breathing but does not address hyperventilation or respiratory alkalosis directly.
D. While encouraging the client to remain calm may help, it is not as effective as teaching specific breathing techniques.
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