A nurse is planning care for a client with acute kidney injury.
The nurse should recognize that which assessment data best supports the nursing diagnosis of Excess Fluid Volume?
Significant fatigue for more than one month.
Wheezing in all lung fields.
Oral fluid intake of 2000 mL in 24 hours.
Pitting edema in bilateral lower extremities.
The Correct Answer is D
Choice A rationale
Significant fatigue for more than one month is a common symptom in acute kidney injury but is a non-specific indicator of fluid volume status. Fatigue can stem from uremia, anemia, or electrolyte imbalances, making it an unreliable isolated sign for confirming excess fluid volume in the context of a nursing diagnosis.
Choice B rationale
Wheezing in all lung fields indicates bronchoconstriction or airway narrowing. While pulmonary edema can occur with excess fluid volume and may present with crackles, wheezing is more indicative of obstructive airway diseases like asthma or chronic obstructive pulmonary disease. It does not directly support a diagnosis of excess fluid volume.
Choice C rationale
An oral fluid intake of 2000 mL in 24 hours describes fluid intake but does not directly indicate fluid volume status relative to output and kidney function. In acute kidney injury, the kidneys' ability to excrete fluid is impaired; therefore, intake alone without considering output or other physical findings is insufficient to diagnose fluid excess.
Choice D rationale
Pitting edema in bilateral lower extremities is a classic clinical manifestation of excess fluid volume. It occurs due to increased hydrostatic pressure in the capillaries, forcing fluid into the interstitial spaces. In acute kidney injury, impaired renal excretion of water and sodium leads to systemic fluid overload, making edema a direct and objective sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A history of migraine headaches is generally not a contraindication for propranolol. In fact, propranolol is often prescribed for migraine prophylaxis due to its beta-blocking effects, which can stabilize vascular tone in the brain and reduce the frequency and severity of migraine attacks.
Choice B rationale
Propranolol can mask the symptoms of hyperthyroidism, such as tachycardia and tremors, and may worsen hypothyroidism. Beta-blockers can also interfere with the peripheral conversion of thyroxine (T4) to triiodothyronine (T3). Therefore, a history of hypothyroidism warrants careful consideration and monitoring.
Choice C rationale
A history of hypertension is an indication for propranolol, as it is a beta-blocker commonly used to manage elevated blood pressure. Its mechanism involves reducing heart rate and myocardial contractility, leading to decreased cardiac output and renin release, thereby lowering systemic vascular resistance.
Choice D rationale
A history of bronchial asthma is a significant contraindication for propranolol. As a non-selective beta-blocker, propranolol can cause bronchoconstriction by blocking beta-2 adrenergic receptors in the bronchial smooth muscles, potentially precipitating severe asthmatic attacks or exacerbating respiratory distress.
Correct Answer is D
Explanation
Choice A rationale
The pathway of flow through the body is not the primary determinant for the severity and management of radiation burns. Unlike electrical burns where current pathway is critical, radiation burns are localized tissue damage caused by energy deposition. While systemic effects can occur with high doses, the immediate burn care focuses on the affected areas.
Choice B rationale
The duration of contact with the agent is a significant factor, as longer exposure generally correlates with a higher absorbed dose of radiation, leading to more severe burns. However, it is not the sole determinant, as the type and intensity of the radiation also play crucial roles. The overall dose is a combination of dose rate and exposure time.
Choice C rationale
The temperature to which the skin is heated is the primary mechanism of thermal burns, where heat directly coagulates proteins and damages cells. Radiation burns, however, are caused by the ionization of molecules and formation of free radicals within the tissue, leading to cellular damage and death, rather than direct heating. The burn severity is not primarily determined by temperature.
Choice D rationale
The type, dose, and length of exposure are the most critical factors determining the severity and clinical presentation of radiation burns. Different types of radiation (alpha, beta, gamma, neutron) have varying penetrative abilities and biological effectiveness. The absorbed dose quantifies the energy deposited, and the duration of exposure directly influences the total dose received, all impacting tissue damage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.