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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. "How often do you punish him by giving him a time-out or by using physical discipline?": This response focuses on the mother's disciplinary methods rather than addressing the child's behavior directly. It may come across as judgmental or critical of the mother's parenting approach and does not provide helpful guidance or support.
B. "Physical punishment is not the best way to modify a child's behavior.": This response is appropriate because it addresses the mother's concern about punishment for the child's behavior. It educates the mother about the ineffectiveness and potential harm of physical punishment in modifying behavior. Instead, positive reinforcement, redirection, and open communication are recommended strategies for guiding children's behavior.
C. "It isn't unusual for him to fondle his genitals, as this is part of his exploration of his body.": This response normalizes the child's behavior of touching and playing with his genitals as part of natural childhood development. It reassures the mother that such behavior is common and not necessarily indicative of abnormality or misconduct. Education about normal childhood sexual development can alleviate parental concerns and promote understanding and acceptance.
D. "Constantly touching the genitals indicates a urinary tract infection in a toddler.": This response is incorrect and may unnecessarily alarm the mother. While frequent touching of the genitals could indicate discomfort or irritation associated with a urinary tract infection in a toddler, it is not the case for a 7-year-old child. Additionally, it is essential to avoid making medical diagnoses without proper assessment by a healthcare professional.
E. "Give him a little time, and he'll grow out of it. He's just too young to understand right now." This response acknowledges the child's developmental stage and suggests that the behavior is likely temporary and will naturally resolve as the child matures. It reassures the mother that the behavior is typical for a child of this age and may not require immediate intervention.
Correct Answer is C
Explanation
A. Discuss the situation with another colleague and formulate a plan: While discussing the situation with a colleague and formulating a plan may seem like a reasonable approach, it may not address the immediate concern of potential impairment. Delays in reporting could result in the impaired nurse continuing to work, posing a risk to patient safety. Therefore, this option is not the most appropriate action in this scenario.
B. Ask the impaired nurse to go home, or the incident will be reported to the manager: While it may be necessary for the impaired nurse to leave work if they are unfit to practice safely, this action should be taken after informing the appropriate authority figures. Additionally, threatening to report the incident to the manager without following through on informing them immediately may not effectively address the issue. Therefore, this option is not the most appropriate action in this scenario.
C. Immediately inform the charge nurse or the nurse manager of the nurse's breath odor: This is the most appropriate action in this scenario. If a nurse suspects that a colleague may be impaired, it is crucial to report it immediately to the charge nurse or nurse manager. Prompt reporting allows for timely intervention to ensure patient safety and address the nurse's well-being. The charge nurse or nurse manager can then take appropriate steps, such as conducting an assessment, intervening as necessary, and following institutional policies and procedures for addressing impairment.
D. Research the state's peer assistance program and discuss the program with the nurse: While peer assistance programs can be valuable resources for nurses experiencing impairment, they are not the most immediate or appropriate action in this scenario. Addressing the issue of potential impairment requires timely reporting to the charge nurse or nurse manager to ensure patient safety and provide support for the impaired nurse. Therefore, this option is not the most appropriate action in this scenario.
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