A patient experiencing multisystem fluid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?
Effects of rapidly infused intravenous fluids.
The body's natural compensatory mechanisms.
Cardiac failure.
Pharmacological effects of a diuretic.
The Correct Answer is B
Choice A Reason: This is incorrect because effects of rapidly infused intravenous fluids are not the cause of the patient's findings, but a possible treatment. Rapidly infused intravenous fluids are used to restore fluid volume and prevent shock in patients with fluid volume deficit. Rapidly infused intravenous fluids can cause increased blood pressure, increased urine output, and decreased heart rate.
Choice B Reason: This is correct because the body's natural compensatory mechanisms are the cause of the patient's findings. The body tries to maintain homeostasis and perfusion in response to fluid volume deficit by activating the sympathetic nervous system, the renin-angiotensin-aldosterone system, and the antidiuretic hormone system. These mechanisms cause tachycardia, vasoconstriction, pale and cool skin, sodium and water retention, and decreased urine output.
Choice C Reason: This is incorrect because cardiac failure is not the cause of the patient's findings, but a possible complication. Cardiac failure occurs when the heart is unable to pump enough blood to meet the body's needs. Cardiac failure can result from prolonged fluid volume deficit, as the heart becomes overstressed and weakened by the increased workload and decreased perfusion. Cardiac failure can cause dyspnea, edema, fatigue, and cyanosis.
Choice D Reason: This is incorrect because pharmacological effects of a diuretic are not the cause of the patient's findings, but a possible cause of fluid volume deficit. A diuretic is a medication that increases urine output and excretion of sodium and water. A diuretic can cause fluid volume deficit if it is overdosed, misused, or taken with other medications that affect fluid balance. A diuretic can cause hypotension, dehydration, and electrolyte imbalances.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A: Contraction of the facial muscle is correct. This is a sign of **Chvostek's sign**, which is a positive indicator of hypocalcemia. Chvostek's sign is elicited by tapping the facial nerve in front of the ear and observing for twitching of the facial muscles.
Choice B: Asked when the foot numbness would go away is correct. This is a sign of **paresthesia**, which is a sensation of numbness, tingling, or prickling in the extremities. Paresthesia is caused by decreased nerve function due to low calcium levels.
Choice C: Carpal spasm with blood pressure measurement is correct. This is a sign of **Trousseau's sign**, which is another positive indicator of hypocalcemia. Trousseau's sign is elicited by inflating a blood pressure cuff above the systolic pressure for 3 minutes and observing for carpal spasm.
Choice D: Complaints of fingers tingling is correct. This is another sign of paresthesia, as explained in choice B.
Choice E: Heart rate 88 and regular is incorrect. This is not a sign of hypocalcemia. Hypocalcemia can cause cardiac arrhythmias, such as prolonged QT interval, ventricular tachycardia, or cardiac arrest. A normal heart rate is between 60 and 100 beats per minute.
Correct Answer is C
Explanation
Choice A: Sodium 155 mEq/L is correct because it indicates hypernatremia, or high sodium level, which can occur in fluid volume deficit due to dehydration, excessive sweating, or diuretic therapy. Sodium is an electrolyte that regulates fluid balance and osmotic pressure in the body. The normal range of sodium is 135 to 145 mEq/L.
Choice B: Hematocrit 44% is incorrect because it is within the normal range of hematocrit, which is the percentage of red blood cells in the blood. Hematocrit can reflect the oxygen-carrying capacity and viscosity of the blood. The normal range of hematocrit is 37% to 47% for females and 42% to 52% for males.
Choice C: Urine specific gravity 1.035 is correct because it indicates a high urine concentration, which can occur in fluid volume deficit due to decreased urine output and increased solute excretion. Urine specific gravity is a measure of the density of urine compared to water. The normal range of urine specific gravity is 1.005 to 1.030.
Choice D: BUN 19 mg/dL is incorrect because it is within the normal range of BUN, which stands for blood urea nitrogen, and is a measure of the amount of nitrogen in the blood that comes from urea, a waste product of protein metabolism. BUN can reflect the kidney function and hydration status of the client. The normal range of BUN is 7 to 20 mg/dL.

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