A nurse is caring for a patient who has been admitted for dehydration. What assessment data will show to nurse the patient's fluid status?
Pedal Pulses
Skin Integrity
Intake and Output
Temperature
The Correct Answer is C
A. Pedal Pulses: While assessing pedal pulses can provide information about circulation, they are not a direct indicator of hydration status. Pulse quality may be affected by other factors such as vascular disease or cardiac output, making this a less reliable measure.
B. Skin Integrity: Skin integrity assesses for potential breakdown or wounds. Although dehydration can affect skin turgor, this alone is insufficient to evaluate fluid balance comprehensively, especially in older adults where elasticity changes naturally with age.
C. Intake and Output: Monitoring fluid intake and urine output provides the most accurate and immediate data on fluid balance. It helps determine if the patient is retaining, losing, or maintaining fluids, making it a primary tool for assessing hydration.
D. Temperature: Elevated temperature may indicate infection or inflammation, which can contribute to fluid loss, but temperature changes alone are not a reliable measure of overall fluid status. It is an indirect and nonspecific indicator.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Encourage the client to share their feelings about smoking cessation: The affective domain of learning involves emotions, feelings, and attitudes. By encouraging the client to share their feelings, the nurse is addressing the client’s emotional response to quitting smoking.
B. Review the strategies for smoking cessation with the client: Reviewing strategies is part of the cognitive domain, which focuses on knowledge and understanding. This method addresses the intellectual aspects of learning, not the emotional or attitudinal components.
C. Discuss the benefits of smoking cessation with the client: Discussing benefits primarily involves the cognitive domain, where the client gains knowledge about the positive effects of quitting smoking. It does not directly address emotions or personal feelings.
D. Create short term goals to assist the client in smoking cessation: Creating goals relates to the psychomotor domain, which involves setting specific, measurable actions. While goal-setting is essential in behavior change, it does not directly engage the emotional or attitudinal aspects of learning.
Correct Answer is ["A","B","C"]
Explanation
A. Foot drop: Foot drop occurs when a person is unable to lift the front part of the foot due to weakness or paralysis of the muscles in the lower leg. Prolonged immobility can lead to contractures and muscle atrophy, increasing the risk of foot drop as the muscles weaken over time.
B. Orthostatic Hypotension: Orthostatic hypotension is a common complication of prolonged bedrest. The lack of movement and the reduced ability to adjust blood pressure upon standing can lead to dizziness, fainting, or falls in immobile patients.
C. Constipation: Constipation a common issue for patients on prolonged bedrest. The lack of movement reduces intestinal motility, leading to difficulty passing stools, which can become a serious concern if not managed properly.
D. Decreased cardiac workload: Immobility generally increases cardiac workload due to the body's need to compensate for the lack of activity. Prolonged bedrest leads to decreased circulation and muscle tone, placing additional strain on the heart.
E. Increased ventilation: Immobility leads to decreased ventilation, not increased. Prolonged bedrest can reduce lung expansion and the ability to clear secretions from the lungs, increasing the risk for respiratory complications such as atelectasis and pneumonia.
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