Which of the following is a clinical manifestation of fluid volume excess quizlet?

3

A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

D --> Patients with burns are susceptible to third-space shifts, resulting in extracellular fluid volume deficit. Extracellular fluid volume deficit is characterized by poor skin turgor, decreased urine output, a rapid and thready pulse, and restlessness. Hyperkalemia is characterized by weakness, irregular pulse, and paresthesias. Hyperphosphatemia is characterized by numbness and tingling, hyperreflexia, tetany, and seizures. Metabolic acidosis is characterized by drowsiness, confusion, decreased blood pressure, dysrhythmias, nausea, and vomiting.

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ANS: 1
Metabolic acidosis may be found in cases of starvation. The client's pH is below the normal of 7.35 (at 7.3), the PaCO2 is in the normal range of 35 to 45 mm Hg (at 38 mm Hg), and the HCO3 is below the normal of 22 mEq/L (at 19 mEq/L). These findings demonstrate metabolic acidosis. Values of pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L are consistent with respiratory alkalosis, compensated, which would not be typical of malnutrition. Values of pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L are consistent with metabolic alkalosis, compensated, which would not be an expected finding with extremely poor nutrition.

ANS: 3
Physical examination of a hyponatremic client may reveal apprehension, personality change, postural hypotension, postural dizziness, abdominal cramping, nausea and vomiting, diarrhea, tachycardia, dry mucous membranes, convulsions, and coma. The remaining options are examples of hypernatremia, hypokalemia, and hyperkalemia.

ANS: 1
Physical examination of a hypernatremic client may reveal extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability. The remaining options are examples of hyponatremia, hypokalemia, and hyperkalemia.

ANS: 4
Physical examination of a hypokalemic client may reveal weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. The remaining options are examples of hypernatremia, hyponatremia, and hyperkalemia.

ANS: 1
Signs of hypokalemia include weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. ECG abnormalities: flattened T wave, ST segment depression, U wave, potentiated digoxin effects (e.g., ventricular dysrhythmias). The most common cause of hypokalemia is vomiting and the use of potassium-wasting diuretics. Signs of hyperkalemia include anxiety, dysrhythmias, paresthesia, weakness, abdominal cramps, and diarrhea. ECG abnormalities: peaked T wave and widened QRS complex (bradycardia, heart block, dysrhythmias) eventually QRS pattern widens and cardiac arrest occurs. Signs of hyponatremia include extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability, whereas signs of hypocalcemia include numbness and tingling of fingers and circumoral (around mouth) region, hyperactive reflexes, positive Trousseau's sign (carpopedal spasm with hypoxia), positive Chvostek's sign (contraction of facial muscles when facial nerve is tapped), tetany, muscle cramps, pathological fractures (chronic hypocalcemia), and ECG abnormalities: ventricular tachycardia.

ANS: 1
Recent surgery is a condition that places clients at high risk for fluid, electrolyte, and acid-base alterations. Clients continue to be at risk during the acute phase until the underlying process is resolved. For example, the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and ADH are increasingly secreted, causing sodium and chloride retention, potassium excretion, and decreased urinary output. The client's diet most likely has not advanced enough to be concerned about excess sodium intake. The client's activity level is important, and the nurse should encourage her to increase her activity level. The client's oxygen level is also important to monitor, but has no direct effect on the fluid, electrolyte, and acid-base alterations

ANS: 1, 2, 3, 5, 6
The greater the body surface burned, the greater the fluid loss. The burned client loses body fluids by one of five routes. First, plasma leaves the intravascular space and becomes trapped edema. This is also called the plasma-to-interstitial fluid shift. It is accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudate. Third, water vapor and heat are lost in proportion to the amount of skin that is burned. Fourth, blood leaks from damaged capillaries, adding to the intravascular fluid volume loss. Finally, sodium and water shift into the cells, further compromising extracellular fluid volume.

ANS: 2, 3, 4, 5, 6
Physical examination of a client experiencing respiratory acidosis may reveal confusion, dizziness, lethargy, headache, ventricular dysrhythmias, warm and flushed skin, muscular twitching, convulsions, and coma. The remaining option is not reflective of respiratory acidosis.

ANS: 1, 2, 3, 5, 6
Physical examination of a client experiencing diabetic ketoacidosis may reveal dry and sticky mucous membranes, flushed and dry skin, thirst, elevated body temperature, irritability, convulsions, and coma. The remaining option is not reflective of diabetic ketoacidosis.

ANS: 2, 3, 5, 6
Physical examination of a client experiencing CHF may reveal rapid weight gain, edema (especially in dependent areas), hypertension, polyuria (if renal mechanisms are normal), neck vein distention, increased blood and venous pressure, crackles in lungs, and confusion. The remaining options are not reflective of CHF.

ANS: 1, 3, 4, 5, 6
When there is a loss of body fluids because of burns, illnesses, or trauma, the client is also at risk for electrolyte imbalance. In addition, electrolyte imbalance may occur from vomiting, diarrhea, or a client's inability to communicate fluid needs, resulting in acid-base disturbances. Trauma, disease, and medications (e.g., diuretics) all contribute to alterations in fluid, electrolyte, and acid-base balance. Schizophrenia itself is not a risk for fluid, electrolyte, or acid-base imbalances.

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