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Exhibits

The nurse reviews the intake information prior to seeing the client.

What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

Temperature 99.9° F (37.7° C)

Respirations 34 breaths/minute

Heart rate 136 beats/minute

Weak peripheral pulses

Dry mucous membranes

Body mass index (BMI) 21.9 kg/m2

Blood pressure 100/52 mm Hg

Poor skin turgor

Answer and Explanation

Correct Answer : C,D,E,G,H

A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.

B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.

C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.

D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.

E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.

F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.

G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.

H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.

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Correct Answer is A

Explanation

A. Glucose and calcium levels: During thyrotoxic crisis, the body’s metabolism is increased, which can lead to hyperglycemia. Additionally, calcium levels may fluctuate due to the impact of thyroid hormones on bone metabolism, making these values critical to monitor.

B. Electrolytes and hemoglobin: While monitoring electrolytes is important, they are not the most critical values in a thyrotoxic crisis. Hemoglobin levels are not directly impacted by thyroid storm and are less likely to provide essential insights for managing this condition.

C. Renal and liver function tests: While important for general health monitoring, renal and liver function tests are not the most critical in the immediate management of a thyrotoxic crisis. The focus should be on metabolic and electrolyte imbalances rather than organ function tests.

D. Blood and urine cultures: Blood and urine cultures are used to detect infections, they are not a priority during a thyrotoxic crisis unless there is a concern about infection. The primary focus should be on managing thyroid hormone levels and associated metabolic effects.

A. Palpate the client's suprapubic area for distention. B. Obtain a urine specimen for culture and sensitivity. C. Instruct in effective techniques to cleanse the glans penis. D. Advise the client to maintain a voiding diary for one week.

Correct Answer is A

Explanation

A. Palpate the client's suprapubic area for distention: The symptoms suggest possible urinary retention, which could be a result of benign prostatic hyperplasia (BPH) or another obstruction. Palpating the suprapubic area for distention is important to assess for urinary retention and determine if the bladder is full.

B. Obtain a urine specimen for culture and sensitivity: Although a urinary tract infection can cause urinary symptoms, the client's presentation is more likely indicative of a physical obstruction such as BPH. A culture might be needed later if infection is suspected.

C. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important, especially in older adult men, but this is not the most relevant action for the symptoms described. The focus should be on assessing for possible urinary retention or obstruction.

D. Advise the client to maintain a voiding diary for one week: While a voiding diary may provide useful information for monitoring symptoms over time, the immediate priority is to assess for urinary retention and bladder distention.

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Exhibits The nurse reviews the intake information prior to seeing the client. What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

Correct Answer is A

Explanation

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Explanation

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Exhibits

The nurse reviews the intake information prior to seeing the client.

What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.