Physiological Health Problems
Question 1
pts
A nurse is assigned to care for four clients on the medical-surgical unit. Which client
should the nurse see first on the shift assessment?
A client undergoing long-term corticosteroid therapy with mild bruising on the anterior
surfaces of the arms
Correct!
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema
A client with congestive heart failure with clear lung sounds on the previous shift
A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis
Rationale: The client who should be seen first is the one with SOB and a history of
pulmonary edema. In light of such a history, SOB could indicate that fluid-volume
overload has once again developed. The client with a fever and who is diaphoretic is at
risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client
is not the priority.
Test-Taking Strategy: Use the process of elimination and focus on the subject of the
question, the client who should be seen first. Recall the rule of assessment of the ABCs
— airway, breathing, and circulation — which means that the client experiencing SOB
should take precedence over the other clients on the unit. This client’s condition could
progress to respiratory arrest if the client were not assessed immediately on the basis of
the signs and symptoms. Read each option and think about the client in most critical
condition and review the disorders to determine which clients have the most critical
needs. If you had difficulty with this question, review the various disease processes
presented in this question.
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th
ed., p. 305). St. Louis: Elsevier.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological
IntegrityIntegrated Process: Nursing Process/Assessment
,Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision Making/Clinical Judgment, Collaboration/Managing
Care
Question 2
pts
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the
hospital with a diagnosis of dehydration. For which clinical manifestations that correlate
with this fluid imbalance would the nurse assess the client? Select all that apply.
Correct!
Decreased urine output
Increased blood pressure
Decreased respiratory depth
Correct!
Increased respiratory rate
Decreased pulse
Rationale: A client with dehydration has an increased depth and rate of respirations.
The diminished fluid volume is perceived by the body as a decreased oxygen level
(hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other
assessment findings in insufficient fluid volume are decreased urine volume, increased
pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with
increased specific gravity, increased hematocrit, and altered level of consciousness.
Increased blood pressure, decreased pulse, and increased urine output occur with fluid-
volume overload.
Test-Taking Strategy: Use the process of elimination and focus on the subject,
dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid
volume. Remember that the body will increase the respiratory rate in an attempt to
maintain the oxygen level. If you had difficulty with this question, review the signs of
insufficient fluid volume.
,Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291-
292). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Clinical Judgment,Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes
Question 3
pts
A nurse is reviewing the medical records of the clients to whom she is assigned on the 7
am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid
volume?
Correct!
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr
A 65-year-old client with a nasogastric tube attached to low suction following partial
gastrectomy
A 35-year old client who is vomiting undigested food after eating
A 48-year-old client receiving diuretics to treat hypertension
Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk
for excessive fluid volume because of the diminished cardiovascular and renal function
that occur with aging. Other causes of excessive fluid volume include renal failure, heart
failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses,
excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is
receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for
deficient fluid volume.
Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk
for excessive fluid volume. Read each option and think about the fluid imbalance that
could occur in each situation; in the case of the incorrect options, it is fluid-volume
deficiency; the only option reflecting conditions that could result in an excess is the
correct option. If you had difficulty with this question, review the causes of excessive
, fluid volume.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291,
293). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Care Coordination, Fluid and Electrolyte Balance
HESI Concepts: Collaboration/Managing Care, Fluid and Electrolytes
Question 4
pts
A nurse is caring for a client who is being treated for congestive heart failure and has
been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding
causes the nurse to determine that the client’s condition has improved?
Dyspnea
1+ edema in the legs
Moist crackles in the lower lobes of the lungs
Correct!
Weight loss of 4 lb (1.8 kg) in 24 hours
Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is
important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1
kg). The other options listed indicate that the client is retaining fluid. Assessment
findings associated with excessive fluid volume include cough, dyspnea, rales or
crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse,
increased central venous pressure, weight gain, edema, neck and hand vein distention,
altered level of consciousness, and decreased hematocrit. These symptoms must be
reversed if the fluid-volume excess is to be resolved.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign
that the client’s condition is improving. The only such finding is decreasing body weight.
Question 1
pts
A nurse is assigned to care for four clients on the medical-surgical unit. Which client
should the nurse see first on the shift assessment?
A client undergoing long-term corticosteroid therapy with mild bruising on the anterior
surfaces of the arms
Correct!
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema
A client with congestive heart failure with clear lung sounds on the previous shift
A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis
Rationale: The client who should be seen first is the one with SOB and a history of
pulmonary edema. In light of such a history, SOB could indicate that fluid-volume
overload has once again developed. The client with a fever and who is diaphoretic is at
risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client
is not the priority.
Test-Taking Strategy: Use the process of elimination and focus on the subject of the
question, the client who should be seen first. Recall the rule of assessment of the ABCs
— airway, breathing, and circulation — which means that the client experiencing SOB
should take precedence over the other clients on the unit. This client’s condition could
progress to respiratory arrest if the client were not assessed immediately on the basis of
the signs and symptoms. Read each option and think about the client in most critical
condition and review the disorders to determine which clients have the most critical
needs. If you had difficulty with this question, review the various disease processes
presented in this question.
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th
ed., p. 305). St. Louis: Elsevier.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological
IntegrityIntegrated Process: Nursing Process/Assessment
,Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision Making/Clinical Judgment, Collaboration/Managing
Care
Question 2
pts
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the
hospital with a diagnosis of dehydration. For which clinical manifestations that correlate
with this fluid imbalance would the nurse assess the client? Select all that apply.
Correct!
Decreased urine output
Increased blood pressure
Decreased respiratory depth
Correct!
Increased respiratory rate
Decreased pulse
Rationale: A client with dehydration has an increased depth and rate of respirations.
The diminished fluid volume is perceived by the body as a decreased oxygen level
(hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other
assessment findings in insufficient fluid volume are decreased urine volume, increased
pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with
increased specific gravity, increased hematocrit, and altered level of consciousness.
Increased blood pressure, decreased pulse, and increased urine output occur with fluid-
volume overload.
Test-Taking Strategy: Use the process of elimination and focus on the subject,
dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid
volume. Remember that the body will increase the respiratory rate in an attempt to
maintain the oxygen level. If you had difficulty with this question, review the signs of
insufficient fluid volume.
,Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291-
292). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Clinical Judgment,Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes
Question 3
pts
A nurse is reviewing the medical records of the clients to whom she is assigned on the 7
am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid
volume?
Correct!
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr
A 65-year-old client with a nasogastric tube attached to low suction following partial
gastrectomy
A 35-year old client who is vomiting undigested food after eating
A 48-year-old client receiving diuretics to treat hypertension
Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk
for excessive fluid volume because of the diminished cardiovascular and renal function
that occur with aging. Other causes of excessive fluid volume include renal failure, heart
failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses,
excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is
receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for
deficient fluid volume.
Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk
for excessive fluid volume. Read each option and think about the fluid imbalance that
could occur in each situation; in the case of the incorrect options, it is fluid-volume
deficiency; the only option reflecting conditions that could result in an excess is the
correct option. If you had difficulty with this question, review the causes of excessive
, fluid volume.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291,
293). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Care Coordination, Fluid and Electrolyte Balance
HESI Concepts: Collaboration/Managing Care, Fluid and Electrolytes
Question 4
pts
A nurse is caring for a client who is being treated for congestive heart failure and has
been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding
causes the nurse to determine that the client’s condition has improved?
Dyspnea
1+ edema in the legs
Moist crackles in the lower lobes of the lungs
Correct!
Weight loss of 4 lb (1.8 kg) in 24 hours
Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is
important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1
kg). The other options listed indicate that the client is retaining fluid. Assessment
findings associated with excessive fluid volume include cough, dyspnea, rales or
crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse,
increased central venous pressure, weight gain, edema, neck and hand vein distention,
altered level of consciousness, and decreased hematocrit. These symptoms must be
reversed if the fluid-volume excess is to be resolved.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign
that the client’s condition is improving. The only such finding is decreasing body weight.
