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A 74-year-old female older adult was admitted to the ER with Shortness of breath, lethargy, and dry oral mucosa. The patient reports being thirsty, and no complaints of pain are noted. BP is 90/50, HR 122, temperature 100, and pulse ox is 94%. The patient is started on IV therapy and has been diagnosed with Dehydration. Her height is 5 Feet, 3 inches and her current weight is 98 pounds. Dark scanty urine present, NKDA or NKFA and has a history of gout, falls, and loss of appetite.

After reviewing the patient's information, identify all pertinent assessment data that is important and of immediate concern.

Select all that apply.

Weight 98Lbs

Dehydrated

Admitted to the ER

Lethargy

HR 122

Shortness of Breath

Temperature 100

Thirsty

Female

BP 90/50

Answer and Explanation

Correct Answer : A,B,D,E,F,G,H,J

● Weight 98 lbs: This information helps determine the patient's baseline weight and assess for potential weight loss associated with dehydration.

● Dehydrated: The diagnosis of dehydration indicates a critical condition that requires immediate attention and intervention.

● Lethargy: Lethargy suggests a decreased level of consciousness and could indicate a severe state of dehydration or other underlying issues that need to be addressed promptly.

● HR 122: A heart rate of 122 beats per minute is elevated and may indicate compensatory mechanisms in response to dehydration or other underlying conditions. It requires further evaluation and intervention.

● Shortness of Breath: This symptom suggests respiratory distress and may be related to the patient's dehydration or underlying conditions. It requires immediate assessment and intervention.

● Temperature 100: An elevated temperature may indicate an underlying infection or inflammatory response. It requires further evaluation to determine the cause and guide appropriate treatment.

● Thirsty: The patient's report of feeling thirsty is an important symptom indicating dehydration and the need for fluid replacement.

● BP 90/50: A blood pressure of 90/50 is low and may be indicative of hypotension, which can occur in dehydration. It requires close monitoring and intervention to stabilize the patient's blood pressure.

The following items are not immediate concerns based on the given information: ● Admitted to the ER: While it is important information, it is not a current concern as the patient is already in the ER.

● Female: The patient's gender is not an immediate concern for the assessment and management of dehydration.

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Correct Answer is D

Explanation

During triage in a disaster situation, a color tagging system is often used to prioritize and categorize the injured based on the severity of their injuries and the urgency of medical attention required. The colors commonly used in triage are:

● Green tag: Minor injuries that are non-urgent and can typically wait for medical treatment.

● Yellow tag: Injuries that are significant but not immediately life-threatening, requiring medical attention within a few hours.

● Red tag: Critical injuries that are life-threatening but still salvageable with prompt medical intervention.

● Black tag: Injuries that are severe and unsurvivable or incompatible with life. This tag is assigned to individuals who are deceased or have injuries that are beyond the resources available for treatment.

In the given scenario, the absence of breathing, absent radial pulse, prolonged capillary refill, and unresponsiveness indicate a critical condition with no signs of life. Therefore, a black tag would be assigned to this individual.

A. Steady gait observed when ambulating. B. Social worker paged for consultation. C. Nursing literature reviewed for best practice approaches. D. Discussed dietary preferences with client.

Correct Answer is D

Explanation

Patient-centered care involves actively involving the patient in their care and considering their preferences, values, and goals. By discussing dietary preferences with the client, the nurse is demonstrating a patient-centered approach. This documentation indicates that the nurse took the time to engage in a conversation with the client to understand their dietary preferences,

which can help tailor the care plan to meet the client's individual needs and preferences. "Steady gait observed when ambulating" focuses on the nurse's observation and assessment but does not specifically involve the patient's preferences or goals.

"Social worker paged for consultation" indicates collaboration with another healthcare professional but does not necessarily reflect the patient's active involvement or preferences. "Nursing literature reviewed for best practice approaches" highlights evidence-based practice but does not directly involve the patient's preferences or engagement in decision-making.

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Naxlex Comprehensive Predictor Exams

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?

Correct Answer is D

Explanation

Which nursing documentation demonstrates the integration of patient-centered care?

Correct Answer is D

Explanation

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