The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

Jugular vein distention

Skin turgor, tenting at clavicular area

Elevated hematocrit

Oral mucous membranes dry and sticky

Answer and Explanation

Correct Answer : B,C,D

A. Jugular vein distention: Jugular vein distention is not typically associated with deficient fluid volume (dehydration). Instead, it is often seen in conditions of fluid overload, such as heart failure or volume overload. Therefore, this finding is not accurate for deficient fluid volume.

B. Skin turgor, tenting at clavicular area: Skin turgor refers to the skin's ability to return to its normal position after being pinched or pulled. In cases of deficient fluid volume (dehydration), skin turgor is decreased, leading to delayed return of the skin to its normal state. Tenting at the clavicular area is a specific sign of decreased skin turgor and is indicative of dehydration.

C. Elevated hematocrit: Deficient fluid volume (dehydration) leads to hemoconcentration, where there is a relative increase in the proportion of red blood cells to plasma volume. As a result, the hematocrit level, which represents the percentage of red blood cells in the total blood volume, increases. An elevated hematocrit is a laboratory finding commonly associated with deficient fluid volume.

D. Oral mucous membranes dry and sticky: Dehydration can lead to decreased saliva production and dryness of the oral mucous membranes. Dry and sticky oral mucous membranes are common clinical signs of deficient fluid volume (dehydration) and indicate inadequate fluid intake or loss.

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Correct Answer is D

Explanation

A. Diarrhea: Diarrhea typically involves the passage of loose or watery stools, often occurring frequently throughout the day. It is characterized by increased frequency, urgency, and volume of stool output. While diarrhea can cause bloating, it is not usually associated with continuous oozing of small amounts of liquid stool.

B. Flatus: Flatus refers to the passage of gas through the rectum, commonly known as "passing gas" or "flatulence." While flatus can contribute to feelings of bloating or discomfort, it does not involve the continuous oozing of liquid stool.

C. Overflow: Overflow typically occurs in the context of fecal impaction, where liquid stool leaks around a fecal mass that is blocking the rectum. However, overflow is characterized by the intermittent leakage of liquid stool, often preceded by constipation and fecal impaction. Continuous oozing of small amounts of liquid stool is not typically associated with overflow alone.

D. Impaction: Fecal impaction occurs when a large, hardened mass of stool accumulates in the rectum, making it difficult or impossible to pass stool. Continuous oozing of small amounts of liquid stool can occur around the impacted fecal mass, leading to symptoms such as bloating, discomfort, and leakage of liquid stool. Therefore, fecal impaction is the most likely condition associated with the client's symptoms.

In summary, option D (Impaction) is the correct answer as it best aligns with the client's symptoms of feeling bloated and experiencing continuous oozing of small amounts of liquid stool in the context of being on bedrest after surgery

A. the person experiencing the pain is the authority about the pain. B. administering analgesics for pain will eventually lead to addiction. C. behavioral signs are always congruent with statements about pain. D. the extent of pain is directly related to the amount of tissue damage.

Correct Answer is A

Explanation

A. The person experiencing the pain is the authority about the pain: This is the most important principle to recognize when caring for a patient in pain. Pain is a subjective experience, and the individual experiencing it is the best authority on their pain. Nurses should listen to and respect the patient's descriptions and assessments of their pain, as they are the ones experiencing it firsthand. This principle underscores the importance of patient-centered care and empowers patients to participate in decisions about pain management.

B. Administering analgesics for pain will eventually lead to addiction: While concerns about addiction are important to consider when administering analgesics, this statement is not the most important principle to recognize when caring for a patient in pain. Fear of addiction should not overshadow the patient's right to adequate pain relief. Nurses should prioritize effective pain management while also considering factors such as the patient's history of substance use and monitoring for signs of misuse or addiction.

C. Behavioral signs are always congruent with statements about pain: While behavioral signs can provide valuable information about a patient's pain experience, they may not always be congruent with verbal statements about pain. Some patients may exhibit stoic behaviors despite experiencing significant pain, while others may express distress more visibly. Nurses should consider both verbal and non-verbal cues when assessing pain and tailor interventions accordingly.

D. The extent of pain is directly related to the amount of tissue damage: While pain often accompanies tissue damage or injury, the extent of pain experienced by an individual is influenced by various factors beyond just tissue damage. Pain perception is subjective and can be influenced by factors such as psychological, emotional, cultural, and social factors. Therefore, pain intensity may not always directly correlate with the amount of tissue damage present.

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The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who is on bedrest after surgery, complains of feeling bloated and having continuous oozing of small amounts of liquid stool. The nurse recognizes this as being symptomatic of which condition?

Correct Answer is D

Explanation

When caring for a patient in pain, the most important principle that the nurse must recognize is that:

Correct Answer is A

Explanation

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