An older adult client experiences a change in mental status. Which assessment finding represents a critical thinking approach?

Type of diet

Cultural considerations

Gender

History of onset

Answer and Explanation

The Correct Answer is D

A. Type of diet: While the type of diet may be relevant to the overall health and well-being of the older adult client, it may not directly contribute to understanding the change in mental status. While nutritional deficiencies or imbalances could potentially impact mental status, other factors are more immediately relevant to assessing the change in mental status.

B. Cultural considerations: Cultural considerations are important in providing holistic care to the older adult client, but they may not directly contribute to understanding the change in mental status. Cultural factors could influence communication styles, beliefs about health and illness, and preferences for care, but they may not be the primary focus when assessing a change in mental status.

C. Gender: Gender may have some relevance to the overall health and well-being of the older adult client, but it may not directly contribute to understanding the change in mental status. While certain gender-related factors, such as hormonal changes or gender-specific health conditions, could potentially impact mental health, they may not be the primary focus when assessing a change in mental status.

D. History of onset: This represents a critical thinking approach because understanding the history of onset of the change in mental status is essential for identifying potential causes and determining appropriate interventions. The timing and circumstances surrounding the onset of the change can provide valuable information about possible contributing factors, such as recent illnesses, medication changes, trauma, or environmental changes. By gathering information about the history of onset, the nurse can engage in critical thinking to formulate hypotheses, prioritize assessments, and develop a plan of care tailored to the client's needs.

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Correct Answer is D

Explanation

A. Diarrhea: Diarrhea typically involves the passage of loose or watery stools, often occurring frequently throughout the day. It is characterized by increased frequency, urgency, and volume of stool output. While diarrhea can cause bloating, it is not usually associated with continuous oozing of small amounts of liquid stool.

B. Flatus: Flatus refers to the passage of gas through the rectum, commonly known as "passing gas" or "flatulence." While flatus can contribute to feelings of bloating or discomfort, it does not involve the continuous oozing of liquid stool.

C. Overflow: Overflow typically occurs in the context of fecal impaction, where liquid stool leaks around a fecal mass that is blocking the rectum. However, overflow is characterized by the intermittent leakage of liquid stool, often preceded by constipation and fecal impaction. Continuous oozing of small amounts of liquid stool is not typically associated with overflow alone.

D. Impaction: Fecal impaction occurs when a large, hardened mass of stool accumulates in the rectum, making it difficult or impossible to pass stool. Continuous oozing of small amounts of liquid stool can occur around the impacted fecal mass, leading to symptoms such as bloating, discomfort, and leakage of liquid stool. Therefore, fecal impaction is the most likely condition associated with the client's symptoms.

In summary, option D (Impaction) is the correct answer as it best aligns with the client's symptoms of feeling bloated and experiencing continuous oozing of small amounts of liquid stool in the context of being on bedrest after surgery

A. Isotonic fluid helps the client feel less thirsty when they are NPO. B. This type of IV hydration replaces blood volume without affecting intracellular fluid. C. Isotonic IV hydration can cause cells to burst if given too rapidly. D. This type of IV fluid must be given in an intensive care setting with frequent monitoring of the client's vital signs.

Correct Answer is B

Explanation

A. Isotonic fluid helps the client feel less thirsty when they are NPO: While isotonic fluids can help maintain hydration status, they do not directly address the sensation of thirst. Isotonic fluids replace extracellular fluid volume and help maintain electrolyte balance but do not affect the sensation of thirst.

B. This type of IV hydration replaces blood volume without affecting intracellular fluid: This is the correct property of isotonic fluid replacement. Isotonic IV fluids have a similar osmolarity to extracellular fluid and thus replace fluid volume without significantly impacting the distribution of water between intra- and extracellular compartments. They are effective for expanding intravascular volume without causing a significant shift of water into or out of cells.

C. Isotonic IV hydration can cause cells to burst if given too rapidly: Isotonic IV fluids have the same osmotic pressure as blood plasma and therefore do not cause cells to burst when administered at appropriate rates. It is hypertonic solutions that can cause cells to shrink or swell due to osmotic imbalances.

D. This type of IV fluid must be given in an intensive care setting with frequent monitoring of the client's vital signs: While isotonic fluids are commonly used in various clinical settings, including intensive care, they do not inherently require administration in an intensive care setting with frequent monitoring of vital signs. Isotonic fluids are often administered in routine medical-surgical settings for various fluid balance problems.

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An older adult client experiences a change in mental status. Which assessment finding represents a critical thinking approach?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who is on bedrest after surgery, complains of feeling bloated and having continuous oozing of small amounts of liquid stool. The nurse recognizes this as being symptomatic of which condition?

Correct Answer is D

Explanation

A client is prescribed isotonic IV hydration for their current fluid balance problem. Which property of isotonic fluid replacement is essential for the nurse to understand?

Correct Answer is B

Explanation

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