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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
To calculate the dose of diazepam in mL, the nurse should use the formula:
Dose (mL) = Desired dose (mg) / Available dose (mg/mL)
Plugging in the values from the question, we get:
Dose (mL) = 3 mg / 5 mg/mL
Simplifying, we get:
Dose (mL) = 0.6 mL
Therefore, the nurse should administer 0.6 mL of diazepam IM.
Correct Answer is A
Explanation
A. B6 (Pyridoxine):
Vitamin B6, also known as pyridoxine, is known to reduce the therapeutic effects of levodopa. It competes with levodopa for absorption in the gastrointestinal tract and can decrease the amount of levodopa that reaches the brain, thereby diminishing its effectiveness in treating Parkinson's disease symptoms.
B. A (Retinol):
Vitamin A, also known as retinol, is not typically associated with reducing the therapeutic effects of levodopa. Vitamin A plays important roles in vision, immune function, and cellular communication, but it does not interact with levodopa in a way that affects its therapeutic efficacy.
C. E (Alpha-Tocopherol):
Vitamin E, also known as alpha-tocopherol, is an antioxidant that plays a role in protecting cells from oxidative damage. While vitamin E supplementation is sometimes used in Parkinson's disease management for its potential neuroprotective effects, it is not known to reduce the therapeutic effects of levodopa.
D. K (Phylloquinone):
Vitamin K, also known as phylloquinone, is primarily involved in blood clotting and bone metabolism. It does not interact with levodopa in a way that reduces its therapeutic effects.
E. C (Ascorbic Acid):
Vitamin C, also known as ascorbic acid, is not known to reduce the therapeutic effects of levodopa. While vitamin C has various roles in the body, including antioxidant activity and immune function support, it does not interfere with levodopa absorption or efficacy.
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