The nurse is performing an assessment on a patient brought to the emergency department for treatment for dehydration. The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. Which diagnosis does the nurse suspect?

Question

Quizplus · Accepted Answer

The patient's symptoms suggest dehydration, which is characteristic of fluid volume deficit (FVD). The rapid respiratory rate and elevated heart rate are the body's compensatory mechanisms to try to maintain adequate tissue perfusion. The low blood pressure and dizziness upon position change also suggest low circulating volume. The cool, clammy skin may be due to vasoconstriction in an effort to redirect blood flow to vital organs. There is no indication of fluid volume excess or mild ECF deficit, and renal failure would present with different symptoms, such as changes in urine output or quality.

The Nurse Is Performing an Assessment on a Patient Brought