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 D
Explanation
A. Alterations in glucose metabolism are common in liver disease but are not directly linked to impaired clotting factor production.
B. Retention of bile salts causes symptoms like pruritus and jaundice, not bleeding due to prothrombin deficiency.
C. Inadequate albumin production contributes to fluid shifts and edema, not directly to impaired clotting.
D. The liver requires vitamin K to synthesize clotting factors, including prothrombin. In liver failure, impaired vitamin K utilization leads to decreased prothrombin production and increased bleeding risk.
Correct Answer is B
Explanation
A. While pain and peritonitis may occur in other abdominal conditions, they are not the most immediate or specific complications following ERCP.
B. Bleeding and perforation are serious potential complications of ERCP due to instrumentation of the biliary and gastrointestinal tract — requiring close post-procedure monitoring.
C. Acidosis and hypoglycemia are unrelated to ERCP and not expected complications of this procedure.
D. Gangrene of the gallbladder and hyperglycemia are not common complications post-ERCP, especially after stone removal rather than acute cholecystitis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.