A community health nurse is performing a home visit to an 80-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response?
"I will need to have your medications adjusted, so you will need to be readmitted to the hospital for a complete workup."
"Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids."
"It is normal to be a little confused following surgery, and it is safe not to urinate at night."
"Confusion and bladder issues are a normal consequence of aging, so I am not too concerned."
The Correct Answer is B
A. Hospital readmission is premature at this stage and may not be necessary if the issue can be addressed with education and support.
B. This response addresses the root problem — inadequate fluid intake — and offers a practical solution that promotes hydration while respecting the client’s concern about nocturia. Dehydration can lead to electrolyte imbalances and confusion, especially in older adults.
C. Confusion is not a normal post-op state and should never be dismissed. Urination at night is common but should not come at the expense of hydration.
D. While aging can bring some changes, confusion and dehydration should never be considered normal or acceptable and require assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hepatitis E virus is transmitted primarily through the fecal-oral route, so following proper hand-washing techniques is essential to prevent infection.
B. Avoiding liver-toxic chemicals helps maintain liver health but does not prevent hepatitis E infection.
C. Avoiding contaminated water and food also helps prevent hepatitis E since it is often spread through contaminated sources.
D. Limiting alcohol intake supports liver health but is not a direct preventive measure against hepatitis E virus.
Correct Answer is C
Explanation
A. While treatment decisions may be necessary, they are typically made with medical guidance and are not usually the primary psychosocial concern.
B. Spiritual distress can occur but is less commonly reported than body image issues in younger clients with visible physical changes.
C. Disturbed body image is a key psychosocial concern in Cushing syndrome, especially in young adults, due to physical changes like moon face, truncal obesity, and skin alterations that can significantly affect self-esteem.
D. Feelings of powerlessness may arise but are generally secondary to the distress caused by altered appearance and self-perception.
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