Asked by Arianna Perez on Jun 22, 2024

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The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.)

A) Test for skin tenting.
B) Measure rate and character of pulse.
C) Measure postural blood pressure and heart rate.
D) Check Trousseau's sign.
E) Observe for flatness of neck veins when upright.
F) Observe for flatness of neck veins when supine.

ECV Deficit

Extracellular Volume (ECV) Deficit is a medical condition where there is a reduction in the volume of fluid outside of cells, which can lead to dehydration and electrolyte imbalances.

Skin Tenting

A sign of dehydration that occurs when skin that is pinched and lifted takes some time to return to its normal position.

Trousseau's Sign

A clinical sign where inflation of a blood pressure cuff on the arm causes a carpal spasm, indicating hypocalcemia.

  • Learn to determine hydration status and recognize symptoms of fluid or electrolyte imbalances in patients.
  • Recognize the signs and symptoms of fluid overload and fluid deficit and understand their implications.
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AA
Ahmed AbdallaJun 23, 2024
Final Answer :
A, B, F
Explanation :
ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau's sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.