A nurse is performing an admission assessment on an older patient who presented with a high fever and cough, reduced oral intake for 3 days, and lower extremity weakness. The patient has sunken eyes, and the patient’s skin turgor over the sternum is poor. The nurse suspects that the patient is dehydrated. Which of the following are indicators of dehydration in this patient? (Select all that apply.)
Sunken eyes
Lower extremity weakness
High fever
Cough
Correct Answer : A,B
Choice A reason: Sunken eyes are a sign of dehydration because the fluid loss causes the eyes to lose their shape and appear hollow. This is especially noticeable in older adults who have less fat and muscle around the eyes.
Choice B reason: Lower extremity weakness is a sign of dehydration because the fluid loss affects the blood volume and circulation, leading to reduced oxygen and nutrient delivery to the muscles. This can cause muscle fatigue, cramps, and weakness.
Choice C reason: High fever is not a sign of dehydration, but rather a possible cause of dehydration. Fever increases the body temperature and metabolic rate, which leads to increased sweating and fluid loss. However, fever itself does not indicate dehydration, unless it is accompanied by other signs and symptoms.
Choice D reason: Cough is not a sign of dehydration, but rather a possible cause of dehydration. Coughing can cause fluid loss through the respiratory tract, especially if it is productive or associated with vomiting. However, cough itself does not indicate dehydration, unless it is accompanied by other signs and symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals who have had a previous episode of Herpes Zoster (HZ), as long as they are not currently experiencing an acute outbreak. The vaccine can help prevent future recurrences of HZ, as well as reduce the risk of postherpetic neuralgia, a painful complication of HZ.
Choice B reason: This statement is correct because the zoster vaccine Shingrix is recommended for all individuals over age 50 that have no contraindications to the vaccine, such as a history of severe allergic reaction to any component of the vaccine, or a current severe immunodeficiency. The vaccine can help prevent HZ and its complications, which are more common and severe in older adults.
Choice C reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals with a chronic cardiac or respiratory condition, as long as they are not immunocompromised. The vaccine is not a live vaccine, so it does not pose a risk of causing or worsening the underlying condition. The vaccine can help protect the individuals from HZ and its complications, which can exacerbate their condition or interfere with their treatment.
Choice D reason: This statement is incorrect because the zoster vaccine Shingrix does not always prevent an individual from developing Herpes Zoster. The vaccine has a high efficacy rate of about 90%, but it is not 100%. The vaccine can reduce the severity and duration of HZ, as well as the risk of postherpetic neuralgia, if it does occur..
Correct Answer is C
Explanation
Choice A reason: Changing facial expression is not a likely action to be observed during the assessment, as PD causes reduced facial expression or mask-like face. The client may have difficulty blinking, smiling, or showing emotions.
Choice B reason: Frequent movement is not a likely action to be observed during the assessment, as PD causes slowed movement or bradykinesia. The client may have difficulty initiating, continuing, or completing movements.
Choice C reason: Resting hand tremors is a likely action to be observed during the assessment, as PD causes rhythmic shaking of the hands, fingers, or other body parts. The tremors usually occur when the affected limb is at rest and may decrease when the client is performing tasks.
Choice D reason: Fast movements is not a likely action to be observed during the assessment, as PD causes impaired movement or dyskinesia. The client may have involuntary, jerky, or twisting movements that are often unpredictable and uncontrollable.
Choice E reason: None of the above is not the correct answer, as there is one choice that is a likely action to be observed during the assessment.
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