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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 ["B","C","D","E","F"]

Explanation

The normal physiological changes of aging that the nurse can expect in an older adult during a musculoskeletal assessment include:

● Widened Gait: With age, there can be a natural widening of the gait due to changes in balance and stability.

● Kyphosis: Kyphosis refers to an increased curvature of the thoracic spine, commonly known as a "hunchback" appearance, which can occur due to changes in the vertebral bones and intervertebral discs.

● Slowed movement: Older adults may experience a natural decline in their movement speed due to changes in muscle strength, coordination, and reaction time. ● Muscle atrophy: Age-related muscle atrophy, or loss of muscle mass, can occur, particularly if the older adult leads a sedentary lifestyle or has other underlying health conditions.

● Decreased joint ROM (Range of Motion): Older adults may experience a gradual decrease in joint flexibility and range of motion due to changes in the joints, ligaments, and surrounding tissues. This can affect their ability to move joints fully.

It's important to note that while some older adults may develop arthritis, it is not considered a normal physiological change of aging. Arthritis refers to the inflammation and degeneration of joints, which can occur due to various factors, including age, genetics, and lifestyle.

A. Skin rash B. Hyperglycemia C. Dizziness D. Intense pruritus

Correct Answer is ["A","D"]

Explanation

Signs and symptoms associated with a hypersensitivity reaction to cephalosporin antibiotics can include:

1. Skin rash: Hypersensitivity reactions often manifest as skin rashes, which can range from mild to severe. The rash may be itchy, red, raised, and may spread to different areas of the body.

2. Intense pruritus: Pruritus refers to severe itching, which can be a prominent symptom of a hypersensitivity reaction to cephalosporins.

Dizziness and hyperglycemia are not commonly associated with hypersensitivity reactions to cephalosporins. Dizziness may be a side effect of some medications, including antibiotics, but it is not a specific symptom of a hypersensitivity reaction. Hyperglycemia, or high blood sugar levels, is not typically attributed to a hypersensitivity reaction to cephalosporins. It's important to note that hypersensitivity reactions can vary in severity and may include other symptoms such as fever, swelling, difficulty breathing, wheezing, and anaphylaxis. If a hypersensitivity reaction is suspected, it is crucial to seek immediate medical attention for proper evaluation and management.

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Naxlex Comprehensive Predictor Exams

A nurse is performing a musculoskeletal assessment on an older adult. What normal Physiological changes of aging does the nurse expect?

Correct Answer is ["B","C","D","E","F"]

Explanation

What signs and symptoms are associated with a hypersensitivity reaction that can present with a Cephalosporin?

Correct Answer is ["A","D"]

Explanation

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Celecoxib is what class of drug?

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