A nurse is collecting data on a client who reports only being able to tolerate drinking small amounts and having diarrhea for several days. Which of the following findings should the nurse expect?
Rigid abdomen
Decreased bowel sounds
Hypothermia
Dehydration
The Correct Answer is D
A. Rigid abdomen: A rigid abdomen suggests peritonitis or another surgical emergency, not dehydration.
B. Decreased bowel sounds: Diarrhea usually causes hyperactive bowel sounds, not decreased.
C. Hypothermia: Clients with diarrhea or fluid loss usually present with normal or elevated temperatures, especially if infection is involved.
D. Dehydration: Diarrhea and limited fluid intake lead to dehydration, which presents with dry mucous membranes, increased thirst, tachycardia, and concentrated urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urge incontinence: Caused by an overactive bladder leading to sudden, intense urge to void-not primarily related to spinal injury.
B. Overflow incontinence: Occurs when the bladder cannot empty properly, leading to dribbling; usually related to obstruction or impaired detrusor muscle, not nerve reflex damage.
C. Stress incontinence: Triggered by pressure (e.g., coughing, sneezing), not neurological issues.
D. Reflex incontinence: Occurs due to neurologic impairment (e.g., spinal cord injury), where the bladder empties without warning or urge.
Correct Answer is ["B","C","E","F"]
Explanation
Mucous membranes pink, skin warm and dry: These are normal findings and do not require follow-up.
Coughing and clearing throat when eating: This suggests possible aspiration, especially concerning in post-stroke clients.
Voice hoarse after swallowing: A hoarse voice post-swallow is a red flag for aspiration risk and should be evaluated promptly.
Temperature 38 °C (100.4°F): This is a low-grade fever and not immediately concerning without other symptoms.
Bilateral breath sounds with wheezing heard in upper lobes: New-onset wheezing indicates possible airway inflammation, aspiration pneumonia, or respiratory distress.
Oxygen saturation 88% on room air: An O₂ saturation below 90% indicates hypoxemia, requiring immediate attention and supplemental oxygen.
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