A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated?

Recent onset of confusion

Cool, clammy skin

Decrease in pulse rate

Increase in blood pressure

Answer and Explanation

The Correct Answer is A

Choice A: This is correct. Dehydration can cause electrolyte imbalance and affect the brain function, leading to confusion, dizziness, or lethargy.

Choice B: This is incorrect. Cool, clammy skin is a sign of shock, not dehydration. Dehydration can cause dry, warm skin.

Choice C: This is incorrect. Decrease in pulse rate is a sign of bradycardia, not dehydration. Dehydration can cause increase in pulse rate as the body tries to compensate for the low blood volume.

Choice D: This is incorrect. Increase in blood pressure is a sign of hypertension, not dehydration. Dehydration can cause decrease in blood pressure as the blood volume drops.

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Correct Answer is D

Explanation

Choice A reason: Cheese is a dairy product that contains protein and fat but little or no fiber.

Choice B reason: Eggs are an animal product that contains protein and fat but no fiber.

Choice C reason: Yogurt is a dairy product that contains protein and calcium but little or no fiber.

Choice D reason: Pears are a fruit that contains dietary fiber, which can help prevent constipation, lower cholesterol levels, and regulate blood sugar levels.

A. Analgesia should be used around the clock to promote pain control. B. Pain patches are applied each morning and removed at bedtime. C. We will use intramuscular medications to control your pain. D. A medication dose must be decreased if you develop tolerance.

Correct Answer is A

Explanation

Choice A reason: Using analgesia around the clock is an appropriate action. The nurse should follow the principle of prevention rather than rescue when managing pain for a client who has terminal cancer. The nurse should administer analgesics on a regular schedule to maintain a steady level of pain relief and prevent breakthrough pain.

Choice B reason: Applying pain patches each morning and removing them at bedtime is not an appropriate action. The nurse should follow the manufacturer's instructions for applying and removing pain patches. Some patches are designed to be worn for 24 hours, while others are worn for 72 hours. Removing the patches too soon can cause inadequate pain control and withdrawal symptoms.

Choice C reason: Using intramuscular medications to control pain is not an appropriate action. The nurse should avoid using intramuscular route for administering analgesics to a client who has terminal cancer. Intramuscular injections are painful, unreliable, and increase the risk of infection and bleeding. The nurse should use oral, transdermal, or subcutaneous routes whenever possible.

Choice D reason: Decreasing a medication dose if the client develops tolerance is not an appropriate action. The nurse should understand that tolerance is a normal physiological response to long-term opioid use and does not indicate addiction or abuse. The nurse should adjust the medication dose according to the client's level of pain and response to treatment.

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A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated?

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