A nurse is collecting data from a patient who has dehydration. Which of the following findings should the nurse expect?
Moist skin
Dark-colored urine
High blood pressure
Distended neck veins
The Correct Answer is B
Choice A reason: Moist skin is not a sign of dehydration, but rather a sign of adequate hydration or sweating. Dehydration can cause dry skin, mucous membranes, and lips.
Choice B reason: Dark-colored urine is a sign of dehydration, as it indicates a high concentration of waste products and a low volume of water in the urine. Dehydration can cause the kidneys to conserve water and produce less urine.
Choice C reason: High blood pressure is not a sign of dehydration, but rather a sign of fluid overload or other factors such as stress, pain, or medication. Dehydration can cause low blood pressure, as it reduces the blood volume and the cardiac output.
Choice D reason: Distended neck veins are not a sign of dehydration, but rather a sign of fluid overload or right-sided heart failure. Dehydration can cause flat neck veins, as it reduces the venous return and the central venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Elderly patients are at a higher risk for dehydration due to physiological changes that come with aging, such as decreased kidney function and physical changes to the body's water balance systems. Additionally, fever increases metabolic rate and fluid loss, and nausea and vomiting prevent adequate fluid intake, further increasing the risk of dehydration.
Choice B: While intentionally limiting fluid intake can lead to dehydration, the body's thirst mechanism in a healthy teenager is typically strong enough to prevent severe dehydration.
Choice C: Diarrhea can certainly lead to dehydration, but a young, otherwise healthy patient typically has a stronger ability to recover from fluid loss than an elderly patient.
Choice D: Infants are at a higher risk for dehydration than older children and adults due to their smaller body weight and higher turnover of water and electrolytes, but in this case, the elderly patient's multiple risk factors put them at a higher risk overall.
Correct Answer is B
Explanation
Choice A reason: Panting with mouth open is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the risk of hyperventilation and respiratory alkalosis, which could worsen the anxiety and cause symptoms such as dizziness, tingling, and muscle spasms.
Choice B reason: Sitting up is an appropriate intervention for an anxious patient with a high respiratory rate. This could help the patient relax and breathe more deeply and slowly, which could reduce the anxiety and normalize the blood gas levels.
Choice C reason: Lying down is not an appropriate intervention for an anxious patient with a high respiratory rate. This could make the patient feel more claustrophobic and increase the anxiety and the respiratory rate.
Choice D reason: Breathing through a re-breather mask is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the oxygen concentration in the blood, which could reduce the stimulus for breathing and cause respiratory depression.
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