A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching?
"I will put beverages in large containers to give the appearance of drinking a lot.”.
"I should consume most of the fluid during the evening.”.
"I will make a list of my favorite beverages.”.
"I will not add ice cream to the amount of fluid intake.”.
The Correct Answer is C
The correct answer is Choice C: "I will make a list of my favorite beverages."
Choice A rationale: Stating that they will put beverages in large containers to give the appearance of drinking a lot demonstrates a lack of understanding of fluid restriction guidelines. It focuses on the appearance rather than the actual fluid intake limitation. This statement does not reflect an understanding of the need to limit fluids in acute kidney disease.
Choice B rationale: Consuming most fluids during the evening is not recommended for clients with acute kidney disease as it may lead to discomfort, nighttime urination, and fluid overload. This statement does not demonstrate an understanding of the importance of spreading fluid intake throughout the day.
Choice C rationale: Making a list of favorite beverages indicates the client's understanding of fluid restrictions. This approach can help the client prioritize their preferred beverages while staying within their prescribed fluid allowance. It shows that the client is aware of the need to be selective in their fluid intake.
Choice D rationale: Although avoiding ice cream is an appropriate action due to its contribution to fluid intake, this statement alone does not necessarily indicate a comprehensive understanding of fluid restrictions. The client must also be aware of the importance of monitoring all sources of fluid intake, including other foods and beverages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Using a microwave for cooking is not a safety risk.
Choice B rationale:
Electrical cords along the walls are not a safety risk.
Choice C rationale:
Handrails in the bathroom are not a safety risk.
Choice D rationale:
Scatter rugs in the kitchen can cause falls, hence they are a safety risk.
Correct Answer is []
Explanation
Condition Most Likely Experiencing:
Delirium
- Explanation: The client has acute confusion, disorganized thinking, restlessness, incoherent speech, and altered sleep-wake cycle—all classic signs of delirium. The sudden onset (starting the previous evening) and fever (38.6°C) suggest a potential underlying cause, such as infection or dehydration.
Actions to Take:
Monitor the client's fluid intake and output.
- Explanation: The client has severe fluid imbalance (250 mL intake vs. 2,500 mL output), leading to dehydration, which can contribute to delirium. Monitoring intake and output is critical for managing hydration status.
Encourage family members to stay with the client.
- Explanation: Familiar faces can help reorient the client and reduce agitation. Delirium often improves with familiar environmental cues and reassurance.
Parameters to Monitor:
Sleep-wake cycle.
- Explanation: Disrupted sleep patterns are a key symptom of delirium. Tracking sleep can help assess improvement or worsening of the condition.
Fall risk.
- Explanation: The client is attempting to get out of bed without assistance, which puts them at high risk for falls. Close monitoring is essential to prevent injury.
Incorrect Choices and Explanations:
Request a prescription for benzodiazepine.
- Why Incorrect? Benzodiazepines can worsen delirium, especially in older adults, by increasing confusion and fall risk.
Assist the client to identify coping skills.
- Why Incorrect? Delirium is an acute medical condition, not a psychological disorder. The focus should be on treating the underlying cause, not psychological coping strategies.
Encourage the client to exercise.
- Why Incorrect? The client is confused, weak, and at risk of falls. Exercise is not appropriate at this stage.
BUN level.
- Why Incorrect? While kidney function (BUN) could be affected by dehydration, monitoring fluid balance directly (intake/output) is more immediate and relevant.
Weight loss.
- Why Incorrect? While the client has refused to eat or drink, weight loss occurs over time, whereas the primary concern is acute dehydration and delirium.
Suicidal ideation.
- Why Incorrect? There is no indication of suicidal thoughts. The confusion and agitation are more likely due to delirium than depression.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.