Examkin

Question

Difficulty: EasyPhysiological Adaptation

A nurse is assessing a client who has experienced severe vomiting and diarrhea for the past 48 hours. Which of the following assessment findings should the nurse identify as indicating fluid volume deficit? Select all that apply.

  1. Heart rate of 118 beats per minuteAnswer
  2. B
    Bounding radial pulses
  3. Urine specific gravity of 1.032Answer
  4. D
    Jugular venous distention
  5. Capillary refill of 4 secondsAnswer

Answer

The correct findings indicating fluid volume deficit are a heart rate of 118 beats per minute, a urine specific gravity of 1.032, and a capillary refill of 4 seconds.
In fluid volume deficit, the body attempts to compensate for reduced intravascular volume. The sympathetic nervous system is activated, resulting in tachycardia (such as a heart rate of 118 beats per minute) to maintain cardiac output and peripheral vasoconstriction, which causes delayed capillary refill (such as 4 seconds). The kidneys compensate by retaining water, leading to highly concentrated urine and an elevated urine specific gravity (such as 1.032).

Step-by-Step Solution

1
Analyze the client's history.
The client has a history of severe vomiting and diarrhea, which leads to significant gastrointestinal fluid and electrolyte losses.
Identifying the etiology helps predict the physiological consequence, which in this case is fluid volume deficit (hypovolemia).
2
Evaluate the assessment findings against expected compensatory mechanisms for hypovolemia.
Tachycardia, concentrated urine, and delayed capillary refill align with decreased intravascular volume.
The body compensates for fluid loss by increasing heart rate to maintain cardiac output, shunting blood to vital organs (decreasing peripheral perfusion), and reabsorbing water in the kidneys.
3
Differentiate between signs of fluid volume deficit and fluid volume excess.
Bounding pulses and jugular venous distention are excluded because they signify fluid overload.
Eliminating findings associated with the opposite physiological state ensures accurate identification of the correct options.

Key Concept

Clinical manifestations of fluid volume deficit (hypovolemia) include tachycardia, delayed capillary refill, and increased urine specific gravity due to compensatory mechanisms.
Rate this question

Topics

Physiological Adaptation

More questions from this topic