An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

"Have you experienced hypoglycemia recently?"

"Are you currently taking any diuretic medications?"

"What types of foods do you purchase?"

"What kind of over-the-counter dietary supplements do you take?"

Answer and Explanation

The Correct Answer is B

A. Hypoglycemia is not a primary cause of dehydration, though it can contribute to other symptoms.
B. Asking about diuretic medications is correct because diuretics increase urine output, which can lead to fluid loss and dehydration, particularly in older adults who may not adequately compensate with fluid intake.
C. The types of food purchased can influence hydration status but are not a primary factor in acute dehydration.
D. Over-the-counter supplements may have effects on hydration, but they are not the most immediate concern when assessing risk factors for dehydration.

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Correct Answer is C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

A. Groin B. Heels C. Elbows D. Toes

Correct Answer is A

Explanation

A. The groin is correct because skin folds in obese clients are prone to excessive moisture, which increases the risk of fungal or bacterial infections such as intertrigo. The nurse should inspect these areas for redness, irritation, or signs of infection.
B. The heels are at risk for pressure injuries but are not typically associated with excessive moisture or diaphoresis.
C. The elbows are not a common site for moisture retention and are not a priority for inspection in this case.
D. The toes can be prone to fungal infections (e.g., athlete’s foot), but the primary concern in an obese client with diaphoresis is the skin folds, particularly in the groin and under the breasts.

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An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Correct Answer is C

Explanation

The nurse is assessing a client with a history of obesity. Upon palpation of the client's skin, the nurse notes diaphoresis. The client reports that, "it is always like that." The nurse should thoroughly inspect the skin on what part of the client's body?

Correct Answer is A

Explanation

What is the primary purpose of a nursing health assessment?

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