C. Dry mucous membranes, thready pulse, tachycardia
The nursing diagnosis fluid volume deficit includes extracellular fluid volume (ECV) deficit,
hypernatremia, and clinical dehydration. ECV deficit is characterized by dry mucous
membranes, thready pulse, and tachycardia, among other indicators. Weight loss of 1 lb (0.5
kg) in 1 week could indicate fat loss instead of fluid loss. ECV deficit causes dark yellow
urine rather than pale yellow, which is normal.
,Term 2 of 258
During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid
concentration between ECF and the cells is
A. Osmosis
B. Diffusion
C. Active transport
D. Facilitated Diffusion
A. Osmosis
Osmosis is the movement of water between two compartments separated by a
semipermeable membrane. Water moves through the membrane from an area of low solute
concentration to an area of high solute concentration.
C. 28-year old who has acute pancreatitis
People who have acute pancreatitis frequently develop hypocalcemia because calcium
binds to undigested fat in their feces and is excreted. This is called steatorrhea. This process
decreases absorption of dietary calcium and also increases calcium output by preventing
resorption of calcium contained in gastrointestinal fluids.
B. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it
and when it impairs functioning."
The most appropriate reply by the nurse is to explain to the family member that anxiety is
considered abnormal when it is out of proportion and impairs functioning. Anxiety is a
normal reaction to a realistic danger or threat to biological integrity or self-concept.
C. 42-year old woman with systemic lupus erythematosus and renal failure
Causes of hypermagnesemia include renal failure (especially if the patient is given
magnesium products), excessive administration of magnesium for treatment of eclampsia,
and adrenal insufficiency.
,Term 3 of 258
A patient is diagnosed with hyperphosphatemia. The nurse realizes that this patient might also
have an imbalance of which of the following electrolytes?
A. calcium
B. sodium
C. potassium
D. chloride
1. 48,000
More than 48,000 children have either lost a parent or have a parent who was wounded in
Iraq or Afghanistan.
A. calcium
Excessive serum phosphate levels cause few specific symptoms. The effects of high serum
phosphate levels on nerves and muscles are more likely the result of hypocalcemia that
develops secondary to an elevated serum phosphorus level. The phosphate in the serum
combines with ionized calcium, and the ionized serum calcium level falls.
B. Infant
Infants have the highest percentage (70-80%) of body weight as water. The elderly and
obese individuals have a decreased percentage of body water. An athletic male would
equal about 60-80% body water.
1, 2, 5.
1. Chlordiazepoxide (Librium) is a benzodiazepine. Benzodiazepines are classified as
antianxiety medications and would be appropriately prescribed to
address signs and symptoms of anxiety.
2. Clonazepam (Klonopin) is a benzodiazepine. Benzodiazepines are classified as
antianxiety medications and would be appropriately prescribed to
address signs and symptoms of anxiety.
5. Oxazepam (Serax) is a benzodiazepine. Benzodiazepines are classified as antianxiety
medications and would be appropriately prescribed to address signs and symptoms of
anxiety.
, Term 4 of 258
A client living in a beachfront community is seeking help with an extreme fear of bridges, which is
interfering with daily functioning. A psychiatric nurse practitioner decides to try systematic
desensitization. Which explanation of this treatment should the nurse provide?
1. "Using your imagination, we will attempt to achieve a state of relaxation."
2. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a
relaxation response for the anxiety response."
3. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your
tolerance to anxiety."
4. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to
tolerate."
3. "Through a series of increasingly anxiety-provoking steps, we will gradually increase
your tolerance to anxiety."
3. The client states that the client feels rested when awakening and denies nightmares.
1. Social isolation R /T fear of germs AEB continually refusing to leave the home.
4. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
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