Which parameters are to be considered in Physical Assessment for Fluid and Electrolyte status? Select all that apply

Daily Weights

Moisture of oral cavity

Intake and Output

Edema

Listen

Skin turgor

Answer and Explanation

Correct Answer : A,B,C,D,F

a) Daily Weights: Daily weights are an important measure for assessing fluid status, as they can indicate fluid retention or loss.

b) Moisture of oral cavity: The moisture of the oral cavity can be an indicator of dehydration, which affects fluid balance.

c) Intake and Output: Monitoring intake and output is essential for assessing the balance of fluids and electrolytes.

d) Edema: Edema, or fluid retention, is a key sign of altered fluid and electrolyte status.

e) Listen: While listening to lung sounds or heart sounds may provide indirect information about fluid balance, the word "listen" alone is too vague and not a specific parameter for fluid and electrolyte assessment.

f) Skin turgor: Skin turgor is a sign of hydration status. Decreased turgor may indicate dehydration.

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Correct Answer is A

Explanation

a) A slowing of the client's heart rate: The Valsalva maneuver (straining during defecation) can cause a transient increase in intra-abdominal pressure, which triggers vagal stimulation, leading to a slowing of the heart rate (bradycardia).

b) A decrease in the client's blood pressure: The Valsalva maneuver may initially cause an increase in blood pressure, followed by a drop after the maneuver is released. The immediate effect is a slowing of the heart rate, not a decrease in blood pressure.

c) An increase in the client's respiratory rate: The Valsalva maneuver typically causes a temporary decrease in respiratory rate due to the strain on the body.

d) A decrease in the client's respiratory rate: The Valsalva maneuver does not typically result in a significant decrease in respiratory rate. Instead, it is more likely to cause a brief alteration in heart rate and blood pressure.

A. I can eat 1-2 oranges B. I will tell my wife that I cannot have grapefruit C. I will not eat my raw vegetables for lunch D. I will need to avoid lamb, beef, and pork

Correct Answer is B

Explanation

a) I can eat 1-2 oranges: Oranges are generally safe to eat prior to a fecal occult blood test. However, vitamin C-rich foods like citrus fruits should typically be avoided in large quantities before the test as they may interfere with the results. A small amount, such as 1-2 oranges, is acceptable.

b) I will tell my wife that I cannot have grapefruit: Grapefruit is rich in vitamin C, and high levels of vitamin C can interfere with the accuracy of the fecal occult blood test. This statement suggests a misunderstanding of which foods to avoid.

c) I will not eat my raw vegetables for lunch: Raw vegetables, particularly cruciferous ones like broccoli and cauliflower, are generally recommended to avoid prior to the test as they can cause false positives. The patient is correct in avoiding them.

d) I will need to avoid lamb, beef, and pork: Red meats like lamb, beef, and pork should be avoided before the test as they can cause false positives. The patient is correct in avoiding these meats.

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Which parameters are to be considered in Physical Assessment for Fluid and Electrolyte status? Select all that apply

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Naxlex Comprehensive Predictor Exams

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?

Correct Answer is A

Explanation

You are the student nurse teaching a patient about what foods to avoid prior to collection of a fecal occult blood test. The patient will need more education if the patient states:

Correct Answer is B

Explanation

Which parameters are to be considered in Physical Assessment for Fluid and Electrolyte status? Select all that apply

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