The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

"I am so depressed living with this pain that I don't know if I can go on anymore."

"At home I take something for pain before it gets too bad."

"I try to pretend that the pain isn't part of me, but it's hard to do."

"I live with pain every day, and it sometimes prevents me from doing the things I love to do."

Answer and Explanation

The Correct Answer is A

This statement raises concern because it suggests that the client is experiencing thoughts of hopelessness and suicidal ideation. Expressions of feeling overwhelmed by pain to the extent of questioning the desire to continue living indicate a need for immediate attention and intervention to address the client's emotional distress and ensure their safety.

B. This statement indicates the client's proactive approach to pain management by taking medication preemptively before pain becomes severe. It reflects an understanding of pain management strategies and a willingness to address pain effectively.

C. Although this statement acknowledges the challenge of coping with pain, it also suggests the client's attempts to cope by mentally dissociating from the pain. While coping mechanisms vary among individuals, this response does not raise immediate concern unless accompanied by more severe signs of distress.

D. This statement acknowledges the chronic nature of the client's pain and its impact on daily activities but does not indicate thoughts of self-harm or severe emotional distress. It reflects the client's adaptation to living with pain and a willingness to engage in activities despite its presence.

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Correct Answer is B

Explanation

When a client experiences increased production of antidiuretic hormone (ADH) and aldosterone due to extreme stress, the body's response is aimed at retaining fluid to maintain blood pressure and hydration. As a result, urinary output decreases because the kidneys retain more water, leading to concentrated urine production. This decrease in urinary output helps conserve fluids and contributes to maintaining blood pressure and hydration levels in response to stress.

A. Serum osmolarity: With increased ADH production, serum osmolarity tends to remain stable or may even increase slightly due to the retention of water. ADH acts on the kidneys to increase water reabsorption, which can concentrate the blood and elevate serum osmolarity.

B. Urinary output: Increased production of ADH and aldosterone leads to decreased urinary output as the kidneys retain more water. This response helps conserve fluid volume and maintain hydration during times of stress.

C. Insensible fluid loss: Insensible fluid loss, which includes water lost through respiration and skin evaporation, is not directly affected by ADH and aldosterone. These hormones primarily influence renal water retention rather than insensible fluid loss.

D. Blood pressure: Although aldosterone can indirectly affect blood pressure by increasing sodium retention and therefore influencing fluid balance, its primary role is to regulate sodium and potassium levels. Blood pressure may be influenced by various factors, including stress, hydration status, and cardiovascular health, but it is not directly decreased as a result of increased ADH and aldosterone production.

A. Serum K+ 3.6 mEq/L B. Urine specific gravity of 1.012 C. Respiratory rate 18 D. +4 Pedal Pulses

Correct Answer is D

Explanation

A. Serum K+ 3.6 mEq/L: Serum potassium (K+) level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically validate fluid volume excess. Serum electrolyte levels can be affected by various factors, including hydration status, renal function, and medications. While hypokalemia (low potassium) may be associated with conditions such as diuretic use or excessive fluid loss, it is not a definitive indicator of fluid volume excess.

B. Urine specific gravity of 1.012: Urine specific gravity measures the concentration of solutes in the urine and can provide information about the client's hydration status. A specific gravity of 1.012 is within the normal range (typically 1.005 to 1.030), indicating that the urine is neither extremely concentrated nor dilute. While changes in urine specific gravity may suggest alterations in fluid balance, a single measurement alone may not be sufficient to validate the client's fluid status, especially in the context of fluid volume excess.

C. Respiratory rate 18: A respiratory rate of 18 breaths per minute falls within the normal range for adults (12-20 breaths per minute) and does not specifically indicate fluid volume excess. Changes in respiratory rate may occur in response to various factors, including respiratory, cardiovascular, or metabolic conditions, but it is not a direct indicator of fluid volume status.

D. +4 Pedal Pulses:

The presence of +4 pedal pulses indicates strong, bounding pulses in the feet. This finding suggests adequate perfusion to the peripheral extremities, which may indicate an appropriate fluid balance. In clients with fluid volume excess, maintaining adequate perfusion to peripheral tissues is essential to prevent complications such as peripheral edema and impaired tissue oxygenation. Strong pedal pulses suggest that perfusion to the lower extremities is not compromised due to hypovolemia or decreased cardiac output, which can be associated with fluid volume deficit.

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The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is under extreme stress will have an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse should expect a decrease in which clinical finding?

Correct Answer is B

Explanation

A nurse is caring for a client being treated for a fluid volume excess. Which clinical finding validates the client's fluid status?

Correct Answer is D

Explanation

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