A nurse is discussing early signs of hypervolemia with a patient admitted with congestive heart failure. Which signs should the nurse include in their teaching?
Increased thirst and dry mucous membranes
Low blood pressure and increased heart rate
Difficulty breathing and weight gain
Dry cough and poor skin turgor
The Correct Answer is C
Choice A reason: This is not a correct sign of hypervolemia. Increased thirst and dry mucous membranes are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.
Choice B reason: This is not a correct sign of hypervolemia. Low blood pressure and increased heart rate are signs of hypovolemic shock, which can occur due to severe fluid loss or hemorrhage.
Choice C reason: This is a correct sign of hypervolemia. Difficulty breathing and weight gain are signs of fluid overload, which can occur due to excessive fluid retention or impaired cardiac function. Difficulty breathing can be caused by pulmonary edema, which is the accumulation of fluid in the lungs. Weight gain can be caused by the increase in total body fluid.
Choice D reason: This is not a correct sign of hypervolemia. Dry cough and poor skin turgor are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement does not suggest that further health education is necessary. The client is expressing a realistic concern about the cost of the medication, which may be expensive or not covered by insurance. The nurse should acknowledge the client's financial situation and provide information about possible assistance programs or alternative options.
Choice B reason: This statement does not suggest that further health education is necessary. The client is expressing a reasonable anxiety about the medication, which may have side effects or interactions that require monitoring. The nurse should reassure the client and explain the purpose and frequency of the blood tests, as well as the potential benefits and risks of the medication.
Choice C reason: This statement does not suggest that further health education is necessary. The client is expressing a sense of wonder or skepticism about the medication, which may be uncommon or novel for the treatment of obesity. The nurse should educate the client about how the medication works and what to expect from the treatment, as well as the evidence and research behind it.
Choice D reason: This statement suggests that further health education is necessary. The client is expressing a false or unrealistic expectation about the medication, which is not a magic pill or a substitute for lifestyle changes. The nurse should correct the client and emphasize the importance of following a healthy diet and exercise regimen, as well as the goals and limitations of the medication.
Correct Answer is B
Explanation
Choice A reason: This is not a correct answer because intracorporeal lithotripsy is a procedure that uses a laser or an ultrasonic probe to break up gallstones inside the gallbladder or the bile ducts. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder.
Choice B reason: This is a correct answer because laparoscopic cholecystectomy is a surgery that removes the gallbladder through small incisions in the abdomen. It is the preferred treatment for cholecystitis, as it eliminates the source of inflammation and prevents further complications.
Choice C reason: This is not a correct answer because extracorporeal shock wave lithotripsy (ESWL) is a procedure that uses shock waves to break up gallstones outside the body. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder and may not be effective for all types of gallstones.
Choice D reason: This is not a correct answer because methyl tertiary butyl ether (MTBE) infusion is a procedure that uses a chemical solvent to dissolve gallstones inside the gallbladder. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder and may cause side effects such as nausea, vomiting, and liver damage.
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