A nurse is evaluating a client who is 70 years old for signs of dehydration.
Which of the following findings should the nurse expect?
Increased skin turgor.
Decreased pulse rate
Increased urine output.
Decreased mental status.
The Correct Answer is D
The correct answer is D.
Decreased mental status. Dehydration in elderly people can cause confusion, disorientation, or drowsiness due to the loss of water and electrolytes from the body.
These symptoms can affect the cognitive function and alertness of the client. Dehydration can also lead to complications such as kidney problems, electrolyte imbalances, or low blood pressure.
Choice A is wrong because increased skin turgor is not a sign of dehydration.
Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled. Dehydration causes decreased skin turgor, meaning the skin stays tented or wrinkled after being pinched.
Choice B is wrong because decreased pulse rate is not a sign of dehydration. Dehydration causes increased pulse rate, as the heart has to work harder to pump blood to the vital organs when there is less fluid in the body.
Choice C is wrong because increased urine output is not a sign of dehydration. Dehydration causes decreased urine output, as the kidneys try to conserve water and produce more concentrated urine.
The urine may also be darker in color than normal.
Normal ranges for fluid intake and output vary depending on age, weight, activity level, and health status.
However, a general guideline is to drink at least eight 8-ounce glasses of water per day and produce at least 30 mL of urine per hour.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Decreased metabolic rate.This is because the metabolic rate is the amount of energy that the body uses to maintain its functions, and it tends to decline with age due to various factors, such as loss of muscle mass, reduced activity, hormonal changes, and decreased thyroid function.
A lower metabolic rate means that the body produces less heat and therefore feels colder more easily.
Choice B is wrong because increased blood pressure is not a normal physiological change with aging, but rather a risk factor for cardiovascular diseases that can be influenced by lifestyle, genetics, and other factors.
Choice C is wrong because increased sweat gland activity is not a normal physiological change with aging, but rather a sign of hyperhidrosis, which is a condition that causes excessive sweating due to overactive sweat glands.Sweat glands actually decrease in number and function with age, which can impair thermoregulation and increase the risk of heat-related illnesses.
Choice D is wrong because decreased body fat is not a normal physiological change with aging, but rather a result of malnutrition, illness, or other causes.Body fat actually tends to increase with age, especially in the abdominal region, due to hormonal changes, reduced physical activity, and lower metabolic rate.
Body fat can act as an insulator and help maintain body temperature.
Normal ranges for metabolic rate vary depending on age, sex, body size, activity level, and other factors.
A general estimate for resting metabolic rate (RMR) is 10 calories per kilogram of body weight per day for men and 9 calories per kilogram of body weight per day for women.
However, this may not reflect the actual metabolic rate of an individual, as it does not account for the effects of food intake, exercise, or environmental factors.
Therefore, it is better to measure metabolic rate using indirect calorimetry or other methods that can capture these variables.
Correct Answer is C
Explanation
The correct answer is C.
Check for bladder distention or fecal impaction.
Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.
It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury.It leads to severe hypertension and is a medical emergency.
Bladder or bowel distension are the most common triggers of autonomic dysreflexia.
Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.
This can help to eliminate the stimulus and lower the blood pressure.
Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.
The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder.Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.
Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure.It may also increase the risk of orthostatic hypotension once the stimulus is removed.However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.
Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia.There is no evidence that body temperature is elevated or contributes to the hypertension in this condition.A cooling blanket may also cause vasoconstriction and worsen the hypertension.
Normal ranges for blood pressure vary depending on age, sex, and other factors.
However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.
Normal ranges for heart rate also vary depending on age, activity level, and other factors.
However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.
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