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: Including foods high in starch and proteins is not a specific dietary instruction for a client who has biliary colic from chronic cholecystitis. Starch and protein intake may vary depending on the client's overall nutritional needs and preferences.
Choice B reason: Including foods high in fiber is a general dietary recommendation for most people, but it is not directly related to biliary colic or cholecystitis. Fiber helps with bowel regularity and may lower the risk of some chronic diseases, but it does not affect the production or flow of bile.
Choice C reason: Avoiding foods high in sodium is a dietary instruction for clients who have hypertension, heart failure, or kidney disease, but it is not relevant for biliary colic or cholecystitis. Sodium intake does not influence the formation or dissolution of gallstones, which are the main cause of biliary colic.
Choice D reason: Avoiding foods high in fat is a dietary instruction for clients who have biliary colic from chronic cholecystitis. Fat intake stimulates the contraction of the gallbladder, which can cause pain and inflammation if there are gallstones blocking the bile ducts. Reducing fat intake can help prevent or reduce the frequency and severity of biliary colic episodes.
Correct Answer is A
Explanation
Choice A reason: Dark-colored stools are an adverse effect of orlistat, a medication that blocks the absorption of fat in the intestines. The unabsorbed fat can cause the stools to become oily, foul-smelling, and dark in color. This can indicate a serious condition called steatorrhea, which can lead to malnutrition and vitamin deficiencies.
Choice B reason: Constipation is not an adverse effect of orlistat. In fact, orlistat can cause the opposite problem of diarrhea, especially if the client consumes too much fat in their diet. Constipation may be caused by other factors, such as dehydration, lack of fiber, or medication side effects.
Choice C reason: Nausea is not an adverse effect of orlistat. Nausea may be a symptom of other conditions, such as gastritis, gastroenteritis, or pregnancy. Nausea may also be caused by other medications, such as antibiotics, opioids, or chemotherapy drugs.
Choice D reason: Abdominal pain is not an adverse effect of orlistat. Abdominal pain may be a sign of other conditions, such as appendicitis, gallstones, or kidney stones. Abdominal pain may also be caused by other medications, such as NSAIDs, steroids, or oral contraceptives.
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