Assessment Findings

Question 1

Fluid volume deficit cardiovascular findings

Answer 1

thready, increased HR
decreased BP and orthostatic hypotension
flat neck
diminished peripheral pulse
decreased central venous pressure
dysrhythmias

Question 2

Fluid volume deficit respiratory findings

Answer 2

increased rate and depth
dyspnea

Question 3

Fluid volume deficit neuromuscular findings

Answer 3

lethargy to coma
fever
skeletal muscle weakness

Question 4

Fluid volume deficit renal findings

Answer 4

decreased urine output

Question 5

Fluid volume deficit integumentary findings

Answer 5

dry skin
poor turgor, tenting
dry mouth

Question 6

Fluid volume deficit GI findings

Answer 6

decreased motility
diminished bowel sounds
constipation
thirst
decreased body weight

Question 7

Fluid volume deficit laboratory findings

Answer 7

all increased

Question 8

Fluid volume excess cardiovascular findings

Answer 8

bounding, increased HR
elevated BP
distended neck
elevated central venous pressure
dysrhythmias

Question 9

Fluid volume excess respiratory findings

Answer 9

increased rate (shallow)
dyspnea
moist crackles on auscultation

Question 10

Fluid volume excess neuromuscular findings

Answer 10

altered LOC
headache
visual disturbance
skeletal muscle weakness
paresthesias (tingling sensation)

Question 11

Fluid volume excess renal findings

Answer 11

increased urine output

Question 12

Fluid volume excess integumentary findings

Answer 12

pitting edema
pale, cool skin

Question 13

Fluid volume excess GI findings

Answer 13

increased motility
diarrhea
increased body weight
liver enlargement
ascites

Question 14

Fluid volume excess laboratory findings

Answer 14

all decreased

Question 15

Hypokalemia cardiovascular findings

Answer 15

thready, weak, irregular pulse
weak peripheral pulse
orthostatic hypotension
dysrhythmias

Question 16

Hypokalemia respiratory findings

Answer 16

shallow, ineffective respiratory from skeletal muscle weakness
diminished breath sounds

Question 17

Hypokalemia neuromuscular findings

Answer 17

anxiety, lethargy, confusion, coma
skeletal muscle weakness, leg cramps
paresthesias
deep tendon hyporeflexia

Question 18

Hypokalemia GI findings

Answer 18

decreased motility
hypoactive to absent bowel sounds
nausea, vomiting, constipation, abdominal distention
paralytic ileus (intestines do not allow food to pass through)

Question 19

Hypokalemia lab findings

Answer 19

potassium level less than 3.5 mEq/L

Question 20

Hypokalemia ECG findings

Answer 20

depressed ST
shallow, flat, or inverted T waves
prominent U waves

Question 21

Hyperkalemia cardiovascular findings

Answer 21

slow, weak, irregular HR
decreased BP
dysrhythmias

Question 22

Hyperkalemia respiratory findings

Answer 22

respiratory failure due to profound weakness of skeletal muscle

Question 23

Hyperkalemia neuromuscular findings

Answer 23

early: muscle twitches, cramps, paresthesias
late: profound weakness

Question 24

Hyperkalemia GI findings

Answer 24

increased motility
hyperactive bowel sounds
diarrhea

Question 25

Hyperkalemia lab findings

Answer 25

potassium level more than 5.0 mEq/L

Question 26

Hyperkalemia 4 ECG findings

Answer 26

flat P waves prolonged PR intervals widened QRS complexes tall T waves

Question 27

Hyponatremia cardiovascular findings

Answer 27

normovolemic: rapid pulse rate, normal BP hypovolemic: thready, weak, rapid pulse rate; hypotension; flat neck veins hypervolemic: rapid, bounding pulse; normal or elevated BP

Question 28

Hyponatremia respiratory findings

Answer 28

shallow, ineffective respiratory due to skeletal muscles weakness

Question 29

Hyponatremia neuromuscular findings

Answer 29

skeletal muscle weakness diminished DTRs

Question 30

Hyponatremia CNS findings

Answer 30

headache confusion seizures coma personality changes

Question 31

Hyponatremia GI findings

Answer 31

increased motility hyperactive bowel sounds diarrhea abdominal cramping

Question 32

Hyponatremia renal findings

Answer 32

increased urine output

Question 33

Hyponatremia integumentary findings

Answer 33

dry mucous membranes

Question 34

Hyponatremia lab findings

Answer 34

sodium level less than 135 mEq/L decreased urinary specific gravity

Question 35

Hypernatremia cardiovascular findings

Answer 35

HR and BP respond to volume status

Question 36

Hypernatremia respiratory findings

Answer 36

hypervolemia: pulmonary edema

Question 37

Hypernatremia neuromuscular findings

Answer 37

early: muscles twitches, irregular muscle contractions late: skeletal muscle weakness, diminished or absent DTRs

Question 38

Hypernatremia CNS findings

Answer 38

altered cerebral function agitation, confusion, seizures lethargy, stupor, coma

Question 39

Hypernatremia GI findings

Answer 39

extreme thirst

Question 40

Hypernatremia renal findings

Answer 40

decreased urinary output

Question 41

Hypernatremia integumentary findings

Answer 41

dry and flushed skin dry and sticky tongue and mucous membranes edema, depending on fluid volume

Question 42

Hypernatremia lab findings

Answer 42

sodium level more than 145 mEq/L increased urinary specific gravity

Question 43

Hypocalcemia cardiovascular findings

Answer 43

decreased HR hypotension diminished peripheral pulses

Question 44

Hypocalcemia neuromuscular findings

Answer 44

twitches, cramps, seizures, tetany painful muscle spasms when inactive paresthesias positive Trousseau's and Chvostek's signs hyperactive DTRs anxiety. irritability

Question 45

Hypocalcemia GI findings

Answer 45

increased motility hyperactive bowel sounds diarrhea cramping

Question 46

Hypocalcemia lab findings

Answer 46

calcium level less than 9.0 mg/dL

Question 47

Hypocalcemia ECG findings

Answer 47

prolonged QT and ST intervals

Question 48

Hypercalcemia cardiovascular findings

Answer 48

early: increased HR late: bradycardia to cardiac arrest increased BP bounding, full peripheral pulses

Question 49

Hypercalcemia respiratory findings

Answer 49

ineffective respiratory due to profound skeletal muscle weakness

Question 50

Hypercalcemia neuromuscular findings

Answer 50

profound muscle weakness diminished or absent DTRs disorientation, lethargy, coma

Question 51

Hypercalcemia GI findings

Answer 51

decreased motility hypoactive bowel sounds constipation, anorexia, nausea, abdominal distention

Question 52

Hypercalcemia lab findings

Answer 52

calcium level more than 10.5 mg/dL

Question 53

Hypercalcemia ECG findings

Answer 53

shorten ST segments widened T waves heart block

Question 54

Hypomagnesemia cardiovascular findings

Answer 54

tachycardia hypertension

Question 55

Hypomagnesemia respiratory findings

Answer 55

shallow

Question 56

Hypomagnesemia neuromuscular findings

Answer 56

twitches, paresthesias positive Trousseau's and Chvostek's signs Hyperreflexia tetany, seizures

Question 57

Hypomagnesemia CNS findings

Answer 57

irritability confusion

Question 58

Hypomagnesemia lab findings

Answer 58

magnesium level less than 1.8 mEq/L

Question 59

Hypomagnesemia ECG findings

Answer 59

depressed ST segments tall T waves

Question 60

Hypermagnesemia cardiovascular findings

Answer 60

bradycardia hypotension

Question 61

Hypermagnesemia respiratory findings

Answer 61

insufficient if respiratory weakness is present

Question 62

Hypermagnesemia neuromuscular findings

Answer 62

diminished or absent DTRs skeletal muscle weakness

Question 63

Hypermagnesemia CNS findings

Answer 63

drowsiness, lethargy, coma

Question 64

Hypermagnesemia lab findings

Answer 64

magnesium level more than 2.6 mEq/L

Question 65

Hypermagnesemia ECG findings

Answer 65

prolonged PR intervals widened QRS complexes