A nurse is assessing an older adult client who has dysphagia and is experiencing dehydration. Which of the following findings should the nurse expect?
Tachycardia
Hypertension
Distended neck veins
Decreased respiratory rate
The Correct Answer is A
The expected finding in an older adult client with dysphagia and dehydration is tachycardia. Tachycardia, an increased heart rate, is a common finding in dehydration as the body tries to compensate for the decreased fluid volume.
The other choices (hypertension, distended neck veins, and decreased respiratory rate) are not typically associated with dehydration in this context.
here's an explanation of why these choices are incorrect:
1. Hypertension: Dehydration usually leads to a decrease in blood volume, resulting in low blood pressure rather than hypertension. Hypertension is not a typical finding in dehydration.
2. Distended neck veins: Dehydration causes a decrease in blood volume, which results in decreased venous return to the heart. Consequently, distended neck veins would not be an expected finding.
3. Decreased respiratory rate: Dehydration itself does not directly affect respiratory rate. However, severe dehydration can lead to electrolyte imbalances, such as hyponatremia (low sodium levels), which can affect brain function and potentially lead to changes in respiratory rate. However, decreased respiratory rate is not a common finding in dehydration alone.
It's important to remember that dehydration can have various signs and symptoms, including dry mucous membranes, decreased urine output, increased thirst, dry skin, dizziness, and confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Administer antiemetics on a schedule. Antiemetics are medications used to prevent or relieve nausea and vomiting. By administering them on a schedule, the nurse can help manage and control the client's nausea more effectively.
Providing a snack 30 minutes before treatments is not an appropriate intervention for nausea associated with radiation therapy. In fact, eating before radiation therapy may worsen nausea in some individuals. It is generally recommended to have a light meal or snack a few hours before the treatment to avoid an empty stomach but also prevent overeating that can trigger nausea.
Ensuring foods are served hot is not a recommended intervention for nausea. In fact, hot foods may exacerbate nausea in some individuals. It is advisable to serve foods at a cooler or room temperature, as cooler foods may be better tolerated.
Serving low carbohydrate meals is not specific to managing nausea associated with radiation therapy. While some individuals may find low carbohydrate meals easier to digest, there is no strong evidence suggesting that they alleviate nausea specifically. The choice of meals should be based on the client's preferences, tolerance, and any dietary restrictions they may have.
Correct Answer is C
Explanation
A) Drinking iced tea with meals can increase the amount of iron absorbed.
- This statement is not correct. Drinking iced tea, especially black tea, can inhibit the absorption of iron. It contains compounds that interfere with the body's ability to absorb non-heme iron, which is found in plant-based foods and supplements. Therefore, this information is not accurate and should not be included in the teaching.
B) Drinking orange juice with iron supplements can decrease absorption.
- This statement is not correct either. In fact, drinking orange juice with iron supplements can enhance iron absorption. This is because orange juice is a good source of vitamin C, which helps the body absorb non-heme iron more effectively. So, this information is inaccurate and should not be included in the teaching.
C) Fish and poultry are primary sources of heme iron.
- This statement is correct. Heme iron is found in animal-based sources like fish and poultry, and it is more readily absorbed by the body compared to non-heme iron from plant-based sources.
D) Cooking in a stainless steel skillet increases the amount of iron in the food.
- This statement is not accurate. Cooking in a stainless steel skillet does not significantly increase the iron content in food. The type of iron in the skillet is not the same as the dietary iron, and it doesn't transfer in significant amounts to the food being cooked. Therefore, this information is not correct and should not be included in the teaching.
So, the nurse should include the information from option C, which is accurate: "Fish and poultry are primary sources of heme iron." Options A, B, and D contain inaccurate information and should be avoided in the teaching to ensure the client receives correct guidance for managing iron deficiency anemia.
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