ATI Exam #1 (Med Surg.) with Complete Solution(SCORED A+)

A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that apply.) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea - ANSWER-A. CORRECT: Decreased skin turgor is a clinical manifestation present with fluid volume deficit. Skin turgor is decreased to due to the lack of fluid within the body and results in dryness of the skin. B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit. The urine is concentrated due to urinary output being decreased. D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit. Low-grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body. E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body. A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative of fluid volume excess? (Select all that apply.) A. Dyspnea B. Edema C. Bradycardia D. Hypertension