A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
Explanation & Rationale
A. Loss of skin turgor occurs when the body is dehydrated, indicating a fluid volume deficit, not excess. Clients with hypervolemia may have taut, shiny, or puffy skin due to fluid retention. Skin turgor is not a reliable indicator of fluid overload in older adults, as elasticity decreases with age. B. Hypervolemia often results in tachycardia as the heart compensates for the increased circulating volume. Bradycardia is not an expected finding and may suggest a separate cardiac conduction issue rather than fluid status. C. A rapid, unexplained weight gain is one of the most reliable indicators of hypervolemia. Even a gain of 2–3 pounds in a day can signal fluid retention. Additional findings may include peripheral edema, jugular vein distention, pulmonary congestion (crackles), dyspnea, and hypertension. Monitoring daily weights and trends in intake and output is essential for early detection and management. D. Hypervolemia typically causes hypertension due to increased circulating volume. Hypotension is more characteristic of hypovolemia or shock, not fluid overload.