Author Question: A teenager is admitted to the medical unit with a significant loss of extracellular fluid (ECF) ... (Read 82 times)

B · **on:** Jul 17, 2018

A teenager is admitted to the medical unit with a significant loss of extracellular fluid (ECF) volume following several sports practices in the extreme heat.

Which sign or symptom is most representative of an early significant loss of extracellular fluid volume that the nurse needs to monitor in the client? A) High urine output
B) Congestive heart failure
C) Hypotension
D) Coma

Question 2

A nurse is assessing a client who has complaints of constipation. During the assessment, the nurse observes that the client's skin feels hot and dry; therefore, the nurse measures the client's body temperature.

What type of observation is the nurse completing with the client? A) Olfactory observation
B) Auditory observation
C) Tactile observation
D) Visual observation

bigsis44 · **Reply #1 on:** Jul 17, 2018

Answer to Question 1

C
Feedback:
The volume of ECF is the most important regulated aspect of body fluid balance. Without adequate ECF, the body cannot maintain normal blood pressure. A significant loss of ECF volume can drop blood pressure to a life-threatening point where cells can no longer function, due to a lack of oxygen and nutrients. Untreated, this can progress to a coma. Too much ECF can place a person in a fluid overload state, leading to high blood pressure and risk for conditions such as congestive heart failure.

Answer to Question 2

C
Feedback:
The nurse uses tactile observation, or the sense of touch, to determine that the client has a temperature, which is confirmed by the thermometer reading. Visual observation includes what has been seen. Auditory observation refers to observations made by hearing or auscultation. Olfactory observation is done on the basis of sense of smell.