Author Question: The nurse is assessing a client for fluid balance. Which findings support a diagnosis of fluid ... (Read 109 times)

sabina

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The nurse is assessing a client for fluid balance. Which findings support a diagnosis of fluid volume deficit?
 
  1. Increased heart rate, increased blood pressure, and cold clammy skin
  2. Decreased blood pressure, increased heart rate, and dry skin
  3. Dry skin, decreased heart rate, and increased blood pressure
  4. Decreased heart rate, decreased blood pressure, and diaphoresis

Question 2

When caring for older clients the nurse should recognize that they are at risk for dehydration related to:
 
  1. decline of the thirst mechanism in the hypothalamus.
  2. excessive antidiuretic hormone (ADH) released by the posterior pituitary.
  3. renal failure.
  4. altered mobility.



ryansturges

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Answer to Question 1

Answer: 2

1. The blood pressure would be low and skin would be dry.
2. Fluid volume deficit is a decrease in extracellular fluid, characterized by a drop in blood pressure and dry skin. The heart rate increases to compensate for the reduction in blood volume.
3. The heart rate would be increased and blood pressure would be low.
4. The skin would be dry and not diaphoretic.

Answer to Question 2

Answer: 1

1. The primary regulator of water intake is thirst, and this mechanism declines in the elderly.
2. With excessive antidiuretic hormone release more water is reabsorbed, fluid volume increases, and urine output is scant and concentrated.
3. Renal failure will cause fluid volume overload.
4. Altered mobility does not cause dehydration.



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