which manifestation should the nurse expect to assess in a patient with fluid volume deficit

HESI LPN

HESI Leadership and Management Quizlet

1. Which manifestation should the nurse expect to assess in a patient with fluid volume deficit?

A. Headache and muscle cramps
B. Dyspnea and respiratory crackles
C. Increased pulse rate and blood pressure
D. Orthostatic hypotension and flat neck veins

Correct answer: D

Rationale: Orthostatic hypotension and flat neck veins are classic manifestations of fluid volume deficit. When the body loses fluid, blood volume decreases, leading to decreased venous return to the heart, resulting in orthostatic hypotension and flat neck veins. Choices A, B, and C are more indicative of other conditions such as dehydration, respiratory issues, or compensatory mechanisms in response to hypovolemia, respectively.

2. A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following should the nurse take first?

A. Refer the AP to the facility procedure manual
B. Demonstrate the proper client transfer technique for the AP
C. Instruct the AP to request assistance when unsure about a task
D. Help the AP assist the client with the transfer

Correct answer: D

Rationale: The correct first action for the nurse is to ensure the safety of the client by immediately intervening to help the AP with the transfer. This hands-on assistance can prevent any potential harm to the client. Referring the AP to the facility procedure manual (Choice A) might take time and delay the necessary immediate action. Demonstrating the proper technique (Choice B) can be done after ensuring the client's safety. Instructing the AP to request assistance (Choice C) is not the most urgent step when a client's safety is at risk.

3. Which anatomic malformations are associated with Tetralogy of Fallot?

A. A sub-aortic septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
B. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and left ventricular outflow
C. A sub-aortic septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
D. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow

Correct answer: D

Rationale: Tetralogy of Fallot is characterized by a combination of four heart defects: a sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow obstruction. This leads to mixing of oxygen-poor and oxygen-rich blood, resulting in cyanosis. Therefore, the correct answer is D. Choices A, B, and C are incorrect because they do not accurately describe the specific combination of anatomic malformations seen in Tetralogy of Fallot.

4. Which of the following chronic complications is associated with diabetes?

A. Dizziness, dyspnea on exertion, and coronary artery disease.
B. Retinopathy, neuropathy, and coronary artery disease.
C. Leg ulcers, cerebral ischemic events, and pulmonary infarcts.
D. Fatigue, nausea, vomiting, muscle weakness, and cardiac arrhythmias.

Correct answer: B

Rationale: The correct answer is B. Diabetes is associated with chronic complications such as retinopathy, neuropathy, and coronary artery disease. Choice A includes symptoms rather than chronic complications of diabetes. Choice C lists conditions not typically associated with diabetes. Choice D describes symptoms that may occur in various medical conditions but are not specific chronic complications of diabetes.

5. A healthcare provider is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regards to client care?

A. Occupational therapist
B. Case manager
C. Nutritionist
D. Psychiatrist

Correct answer: B

Rationale: A case manager is the most appropriate interdisciplinary team member to consult for a client with anorexia nervosa. They can help coordinate care, resources, and communication between various healthcare professionals involved in the client's treatment. Consulting an occupational therapist (Choice A) may not directly address the primary concerns associated with anorexia nervosa. While nutritional therapists (Choice C) play a role in addressing nutritional needs, a case manager is better suited for overall care coordination. Mental health counselors (Choice D) focus more on emotional and psychological aspects, whereas a case manager coordinates practical aspects of care.