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. Which statement about glaucoma is true and accurate?

A. Acute angle-closure glaucoma is an ocular emergency.
B. Acute angle-closure glaucoma leads to the loss of peripheral vision and tunnel vision.
C. Primary open-angle glaucoma leads to eye pain, nausea, and vomiting, blurry vision, and halos.
D. Bubbles are implanted to protect the retina from glaucoma.

Correct answer: A

Rationale: The correct answer is A: 'Acute angle-closure glaucoma is an ocular emergency.' Acute angle-closure glaucoma is indeed considered an ocular emergency that requires immediate attention to prevent vision loss. Choice B is incorrect because acute angle-closure glaucoma commonly presents with symptoms like severe eye pain, headache, blurred vision, and halos around lights. Choice C is incorrect as these symptoms are more indicative of acute angle-closure glaucoma rather than primary open-angle glaucoma. Choice D is incorrect since bubbles are not typically used to protect the retina from glaucoma; treatment usually involves medications, laser therapy, or surgery to manage intraocular pressure.

3. Which patient is exercising their right to autonomy in the context of patient rights?

A. An 86-year-old female who remains independent in terms of the activities of daily living.
B. An unemancipated 16-year-old who chooses to not have an intravenous line.
C. A 32-year-old who does not need the help of the nurse to bathe and groom themselves.
D. A 99-year-old who wants CPR despite the fact that the nurse and doctor do not think that it would be successful.

Correct answer: D

Rationale: The correct answer is D. A 99-year-old exercising their right to autonomy in the context of patient rights by choosing CPR. Autonomy in healthcare refers to the patient's right to make their own decisions about their care, even if healthcare providers may disagree. In this scenario, the 99-year-old patient is exercising autonomy by making an informed choice about their medical treatment, despite healthcare professionals having a different opinion. Choices A, B, and C do not directly demonstrate the exercise of autonomy in decision-making regarding medical treatment, making them incorrect.

4. Which of the following is considered an internal disaster?

A. A patient fall
B. The massive spread of pneumonia
C. A computer hacking episode
D. Unexpected staff absences due to illness

Correct answer: C

Rationale: A computer hacking episode is considered an internal disaster as it disrupts the internal operations of the healthcare facility, compromising data security and potentially impacting patient care. Choices A, B, and D do not directly relate to internal disasters in a healthcare setting. A patient fall is a patient safety issue, the massive spread of pneumonia is a public health concern, and unexpected staff absences due to illness may affect staffing levels but are not typically classified as internal disasters.

5. Which atrioventricular heart block is also referred to as Mobitz II?

A. Third-degree atrioventricular heart block
B. Second-degree atrioventricular heart block
C. First-degree atrioventricular heart block
D. Complete heart block

Correct answer: B

Rationale: The correct answer is B. Second-degree atrioventricular heart block is also known as Mobitz II. In Mobitz II, some atrial impulses are blocked from reaching the ventricles, resulting in occasional dropped beats. Third-degree atrioventricular heart block is known as complete heart block, where no atrial impulses reach the ventricles. First-degree atrioventricular heart block is a condition where there is delayed conduction between the atria and ventricles but all atrial impulses are eventually conducted to the ventricles.