During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?
a slowing of client's heart rate
a decrease in the client's blood pressure
an increase in the client's respiratory rate
a decrease in the client's respiratory rate
The Correct Answer is A
a) A slowing of the client's heart rate: The Valsalva maneuver (straining during defecation) can cause a transient increase in intra-abdominal pressure, which triggers vagal stimulation, leading to a slowing of the heart rate (bradycardia).
b) A decrease in the client's blood pressure: The Valsalva maneuver may initially cause an increase in blood pressure, followed by a drop after the maneuver is released. The immediate effect is a slowing of the heart rate, not a decrease in blood pressure.
c) An increase in the client's respiratory rate: The Valsalva maneuver typically causes a temporary decrease in respiratory rate due to the strain on the body.
d) A decrease in the client's respiratory rate: The Valsalva maneuver does not typically result in a significant decrease in respiratory rate. Instead, it is more likely to cause a brief alteration in heart rate and blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a) Hemoglobin (Hgb) 11.3 g/dL: While a hemoglobin level of 11.3 g/dL is slightly below normal, it is not a definitive indicator of malnutrition. It may be related to anemia but not necessarily malnutrition.
b) Pre-albumin 10 mg/dL: Pre-albumin is a protein that reflects short-term nutritional status. A value of 10 mg/dL is below the normal range and suggests malnutrition, as pre-albumin levels decrease in states of inadequate protein intake.
c) Creatinine 1.9 mg/dL: Elevated creatinine levels typically indicate kidney dysfunction, not malnutrition. It is a marker of kidney health, not nutritional status.
d) Hematocrit (Hct) 56%: A hematocrit level of 56% is elevated, which could indicate dehydration, polycythemia, or other conditions, but it is not a direct indicator of malnutrition.
Correct Answer is A
Explanation
a) Compare the total intake and output of fluids for the 24 hours: To assess fluid balance and status, the nurse must compare the intake and output of fluids. This helps to determine whether the patient is retaining or losing fluids.
b) Compare the patient's intake with the normal range of adult fluid intake: While this is useful for understanding general fluid needs, it does not directly assess the patient's fluid status. The comparison should be between intake and output.
c) Ensure the information is included in the verbal end-of-shift report: While this is good practice, the focus should be on using the information to assess the patient's fluid balance.
d) Report the exact milliliter of intake to the physician's office nurse: The exact intake should be recorded in the patient's chart and used for clinical decision-making, but it does not need to be reported to a physician's office nurse unless specified.
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