The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

Diarrhea

Urinary output

Profuse sweating

Vomiting

Increased respiratory effort

Answer and Explanation

Correct Answer : B,E

A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.

B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.

C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.

D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.

E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.

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Correct Answer is C

Explanation

A. Baked chicken, canned peas & carrots, macaroni & cheese, and hot tea: This meal option contains canned vegetables, which are likely to be high in sodium due to added salt for preservation. Additionally, macaroni and cheese are typically high in sodium, and hot tea may contain added sodium if processed or prepared with salt. Therefore, this option is not suitable for a client on a low-sodium diet.

B. Pepperoni pizza, salad, and a diet soda: Pepperoni pizza is a high-sodium food due to the processed meats and cheese. Salad can be a healthy option, but it depends on the dressing and toppings; if these are high in sodium, it may not be appropriate. Diet soda typically does not contain sodium, but it is not an ideal beverage choice for a client with fluid volume excess. Overall, this option is not suitable for a low-sodium diet.

C. Baked turkey breast, corn on the cob, dinner roll, and skim milk: This is the correct answer. Baked turkey breast is a lean protein source that is naturally low in sodium. Corn on the cob and skim milk are also low in sodium. A dinner roll may contain some sodium, but if chosen wisely, it can be a suitable option for a low-sodium diet. Overall, this meal option provides a balanced and low-sodium meal for a client with fluid volume excess.

D. Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers, and iced tea: Bologna, potato chips, and iced tea are all high-sodium food items and not suitable for a client on a low-sodium diet. While sliced cucumbers are low in sodium, they alone cannot offset the high sodium content of the other items in this meal option.

A. chronic B. visceral C. intractable D. neuropathic E. cutaneous

Correct Answer is ["A","C","D"]

Explanation

A. Chronic:

Chronic pain is characterized by pain that persists beyond the expected time for tissue healing, typically lasting for more than 3 to 6 months.

In this scenario, the client's pain has been present for 1 year, indicating a prolonged duration consistent with chronic pain.

Documenting the pain as chronic provides important information about the nature and duration of the client's pain experience.

C. Intractable:

Intractable pain refers to pain that is difficult to manage or control despite various treatment modalities.

The client's report of intense, sharp pain persisting at a high level (rated 9 out of 10) despite opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and acupuncture suggests that the pain is intractable.

Documenting the pain as intractable highlights the challenges associated with managing the client's pain and the need for additional interventions or referral to specialized pain management services.

D. Neuropathic:

Neuropathic pain arises from damage or dysfunction of the nervous system and is often described as sharp, shooting, burning, or like an electric shock.

The client's description of their leg pain as "an intense sharp quality 'like an electric shock'" is consistent with neuropathic pain.

Documenting the pain as neuropathic helps identify the underlying pathophysiology of the pain and guides appropriate treatment strategies targeting neuropathic pain mechanisms.

B. Visceral:

Visceral pain originates from internal organs and is typically described as deep, dull, or cramping.

While the pain in this scenario is associated with spinal nerve injury, which can involve visceral pain pathways, the client's description of the pain as sharp and electric shock-like is more indicative of neuropathic pain rather than visceral pain.

Therefore, visceral pain may not be an appropriate descriptor for the client's pain experience in this case.

E. Cutaneous:

Cutaneous pain arises from the skin or subcutaneous tissues and is often described as superficial, sharp, or burning.

While the client's leg pain may involve cutaneous innervation, the description provided ("like an electric shock") suggests involvement of deeper structures and neuropathic pain mechanisms rather than purely cutaneous pain.

Therefore, cutaneous pain may not fully capture the nature of the client's pain experience in this scenario.

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The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

What meal option should a nurse choose for a client with fluid volume excess who has been placed on a low-sodium diet?

Correct Answer is C

Explanation

Correct Answer is ["A","C","D"]

Explanation

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