The assessment that indicates a fluid volume excess in a patient in the acute phase of a CVA is:

adventitious breath sounds

weak pulse

hypotension

poor skin turgor

Answer and Explanation

The Correct Answer is A

A. Adventitious breath sounds:

Adventitious breath sounds refer to abnormal lung sounds heard upon auscultation of the chest. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. In the context of fluid volume excess, particularly in the acute phase of a cerebrovascular accident (CVA) or stroke, adventitious breath sounds such as crackles are indicative of pulmonary edema. Pulmonary edema occurs when there is an excessive accumulation of fluid in the lungs, impairing gas exchange and leading to symptoms such as shortness of breath and respiratory distress.

B. Weak pulse:

A weak pulse may suggest poor perfusion or decreased cardiac output rather than fluid volume excess. While decreased cardiac output can be a consequence of heart failure, which may be associated with fluid volume excess, a weak pulse is not a direct indicator of fluid overload. In the acute phase of a CVA, a weak pulse may prompt further assessment for other cardiovascular complications or neurogenic shock.

C. Hypotension:

Hypotension, or low blood pressure, is not typically associated with fluid volume excess. Instead, hypotension may indicate hypovolemia, shock, or other underlying cardiovascular conditions. While hypotension can occur secondary to severe heart failure or fluid overload in some cases, it is not a direct indicator of fluid volume excess in the acute phase of a CVA.

D. Poor skin turgor:

Poor skin turgor is a clinical finding associated with dehydration rather than fluid volume excess. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. In contrast, fluid volume excess is characterized by edema, which may manifest as pitting or non-pitting edema, rather than poor skin turgor. However, in fluid volume excess, the skin may appear stretched or taut due to the accumulation of fluid in the interstitial spaces.

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Correct Answer is B

Explanation

A. Intellectual capacity is not affected:

This statement refers to the fact that ALS primarily affects motor neurons, leading to muscle weakness and paralysis, but it typically does not directly impact cognitive function or intellectual capacity. While cognitive impairment is not a hallmark feature of ALS, some individuals may experience changes in cognitive function or behavior, such as executive dysfunction or frontotemporal dementia, in later stages of the disease. However, depression in ALS is not primarily linked to changes in intellectual capacity but rather to other factors such as altered communication, physical limitations, and loss of autonomy.

B. Communication is altered:

ALS can affect the muscles involved in speech and swallowing, leading to difficulties in communicationAs the disease progresses, patients may experience dysarthria (difficulty speaking clearly) and dysphagia (difficulty swallowing), which can impair their ability to communicate effectively with others. Altered communication can result in frustration, social isolation, and feelings of being misunderstood, all of which are risk factors for depression.

C. Mobility is limited:

ALS causes progressive muscle weakness and paralysis, which can significantly impair mobility over time. As the disease advances, individuals with ALS may become increasingly dependent on mobility aids such as wheelchairs or may require assistance with mobility tasks. Limited mobility can lead to feelings of loss of independence, decreased participation in activities, and increased dependence on caregivers, all of which can contribute to depression.

D. Nutritional intake is poor:

ALS can affect the muscles involved in swallowing and chewing, leading to difficulties with eating and drinking. Dysphagia, or difficulty swallowing, is a common symptom in ALS and can result in poor nutritional intake and weight loss. Malnutrition and weight loss are associated with increased morbidity and mortality in ALS, and they can also contribute to feelings of weakness, fatigue, and overall decline in quality of life, which may exacerbate depression.

A. toes turning up and spreading B. downward curl of the toes C. pain in the big toe D. big toe bending upward

Correct Answer is A

Explanation

A. Toes turning up and spreading:

This description corresponds to the abnormal finding in the Babinski reflex. In a positive Babinski sign, the big toe (hallux) dorsiflexes (turns upward) and the other toes fan out. This response is abnormal in adults but normal in infants up to a certain age.

B. Downward curl of the toes:

This response is typical of the normal plantar reflex, where the toes curl downward (plantar flexion) in response to stimulation of the sole of the foot. It is not indicative of the Babinski reflex.

C. Pain in the big toe:

Pain in the big toe is not a characteristic finding of the Babinski reflex. The Babinski sign is assessed by observing the movement pattern of the toes in response to stimulation, rather than eliciting pain.

D. Big toe bending upward:

The big toe bending upward, or dorsiflexion of the big toe, is a specific component of the positive Babinski sign. However, it is typically accompanied by spreading of the other toes, which is the hallmark feature of the Babinski reflex.

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Correct Answer is B

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