Which assessment finding on a client with hypervolemia indicates to the nurse that the client’s condition may be worsening?

Neck veins are now distended in the sitting position.

Breath sounds can be heard in the right lower lung lobe.

Weight is unchanged from that obtained yesterday.

Nose and ears have a slightly yellow-tinged appearance.

Answer and Explanation

The Correct Answer is A

Choice A reason: Distended neck veins in the sitting position indicate worsening hypervolemia, reflecting increased venous pressure and heart strain. This aligns with cardiovascular assessment, making it the correct finding the nurse would identify as a sign of deteriorating fluid overload in the client.

Choice B reason: Breath sounds in the right lower lobe are normal unless crackles indicate fluid. Distended neck veins are more specific to worsening hypervolemia, making this incorrect, as it’s not a clear sign of deterioration in the nurse’s fluid status assessment.

Choice C reason: Unchanged weight doesn’t indicate worsening hypervolemia, which causes weight gain. Distended neck veins signal increased fluid, making this incorrect, as it’s not a dynamic finding compared to the nurse’s assessment of worsening fluid overload in the client.

Choice D reason: Yellow-tinged nose and ears suggest jaundice, not hypervolemia. Distended neck veins are a direct sign of worsening fluid status, making this incorrect, as it’s unrelated to the nurse’s evaluation of deteriorating hypervolemia in the client’s condition.

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Correct Answer is B

Explanation

Choice A reason: High-fat foods may worsen nausea in hepatitis, reducing appetite further. Fluids and juices provide nutrition and hydration, making this incorrect, as it’s less suitable than the nurse’s recommendation to ensure adequate nutrition in a client with anorexia.

Choice B reason: Increasing fluid intake, including nutrient-rich juices, provides calories and hydration, combating anorexia in hepatitis. This aligns with nutritional support strategies, making it the correct instruction the nurse would give to ensure adequate nutrition for the client.

Choice C reason: Supper timing doesn’t address overall anorexia; small, frequent meals are better. Juices provide easier nutrition, making this incorrect, as it’s less effective than the nurse’s advice to increase fluids for a hepatitis client with poor appetite.

Choice D reason: Three large meals may overwhelm a client with hepatitis and anorexia, worsening intake. Fluids and juices are easier to tolerate, making this incorrect, as it’s not the nurse’s best instruction for ensuring adequate nutrition in this client.

A. Apply supplemental oxygen via nasal cannula. B. Administer intravenous morphine for pain. C. Keep the hard collar in place until cleared. D. Administer intravenous methylprednisolone (Solu-Medrol) as prescribed.

Correct Answer is C

Explanation

Choice A reason: Supplemental oxygen is unnecessary with a normal respiratory rate (16) and stable vitals. Maintaining the collar prevents spinal injury, making this incorrect, as it’s not indicated compared to the nurse’s priority of ensuring spinal stability in a client with a fall history.

Choice B reason: Morphine for pain is premature without confirming spinal stability, as it may mask symptoms. Keeping the collar in place is critical, making this incorrect, as it risks missing neurological changes in the nurse’s care of a potential spinal injury client.

Choice C reason: Keeping the hard collar in place until cleared by imaging prevents worsening of potential spinal injury after a trampoline fall. This aligns with trauma care protocols, making it the correct action for the nurse to take to ensure the client’s safety and stability.

Choice D reason: Methylprednisolone is used for confirmed spinal cord injury, not suspected cases without imaging. Maintaining the collar is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on spinal precautions in a client with numbness and tingling.

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Which assessment finding on a client with hypervolemia indicates to the nurse that the client’s condition may be worsening?

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Naxlex Comprehensive Predictor Exams

A client diagnosed with viral hepatitis is complaining of “no appetite” and “losing my taste for food.” What instruction would the nurse give the client to provide adequate nutrition?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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