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A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- A. Urine specific gravity 1.034
- B. Bounding pulse
- C. BP 146/94 mm Hg
- D. Distended neck veins
Correct Answer: A
Rationale: The correct answer is A: Urine specific gravity 1.034. Urine specific gravity measures the concentration of solutes in the urine, and a value of 1.034 indicates highly concentrated urine, which is a sign of dehydration. When the body is dehydrated, the kidneys conserve water, leading to concentrated urine.
Choice B, a bounding pulse, is a sign of fluid volume overload rather than dehydration. Choice C, high blood pressure, is not a direct indicator of dehydration. Choice D, distended neck veins, may be seen in conditions like heart failure but are not specific to dehydration. Overall, urine specific gravity is the most direct and reliable indicator of dehydration in this scenario.
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A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have?
- A. 3.6 mg/dL
- B. 9 mg/dL
- C. 18.7 mg/dL
- D. 24 mg/dL
Correct Answer: D
Rationale: The correct answer is D: 24 mg/dL. BUN (Blood Urea Nitrogen) levels typically increase in dehydration due to reduced kidney perfusion. A BUN level of 24 mg/dL is higher than normal (7-20 mg/dL) and is indicative of dehydration. Choice A (3.6 mg/dL) is too low for a dehydrated client. Choice B (9 mg/dL) is within the normal range and not high enough for dehydration. Choice C (18.7 mg/dL) is slightly elevated but may not be as indicative of dehydration as choice D.
A nurse is assisting with the readmission of a client to the medical unit after a transfer to ICU following a suicide attempt using an overdose of medication. The client looks down at the floor and mumbles, 'Hello.' Which of the following responses should the nurse make?
- A. You have been transferred back to this unit. This is your new room.
- B. Hello. I see that in ICU you've been getting a light diet. How does your stomach feel now?
- C. I was upset when I found you had tried to kill yourself.
- D. Would you like to talk about what happened?
Correct Answer: D
Rationale: Encouraging open communication provides emotional support and helps the client process their feelings.
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?
- A. Nonverbal communication conveys less truth than what the client states verbally.
- B. The client's sociocultural background influences nonverbal communication.
- C. Nonverbal communication is a poor reflection of what the client feels.
- D. The client enacts nonverbal communication consciously.
Correct Answer: B
Rationale: The correct answer is B: The client's sociocultural background influences nonverbal communication. Nonverbal communication is greatly impacted by an individual's cultural norms, values, and beliefs. This influences gestures, facial expressions, posture, and personal space preferences. Understanding the client's sociocultural background helps the nurse interpret nonverbal cues accurately.
Choice A is incorrect because nonverbal communication can often convey more truth than verbal statements as it can be more spontaneous and genuine. Choice C is incorrect because nonverbal behavior can provide valuable insights into a client's true feelings and emotions. Choice D is incorrect because nonverbal communication is often unconscious and can be influenced by subconscious factors.
A nurse is caring for a client who wants information about a complementary or alternative healing modality to help her reduce stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness?
- A. Reiki
- B. Aromatherapy
- C. Acupuncture
- D. Yoga
Correct Answer: D
Rationale: Yoga combines physical postures, breathing exercises, and meditation to reduce stress and promote well-being.
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.)
- A. Shallow respirations
- B. Cardiac dysrhythmias
- C. Flushing
- D. Hyperactive reflexes
- E. Abdominal pain
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Shallow respirations (A) occur as a compensatory mechanism to retain CO2 and decrease pH. Cardiac dysrhythmias (B) can result from electrolyte imbalances associated with alkalosis. Hyperactive reflexes (D) are a sign of neuromuscular irritability due to altered electrolyte levels. Flushing (C) and abdominal pain (E) are not typically associated with metabolic alkalosis. In summary, the nurse should monitor for shallow respirations, cardiac dysrhythmias, and hyperactive reflexes in a client with metabolic alkalosis, as they are indicative of the condition and its complications.