The community health nurse is performing a home visit for a 74-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. The client states to stop drinking water early in the day because it's just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response?
You need to have your medications adjusted so you need to be admitted to the hospital for a complete workup.
You build up too much urine in your bladder, which can cause you to get confused.
Dehydration can cause changes that can result in confusion, so let's try to increase your fluid intake.
Urinary tract infections are common and can cause confusion, so it's important not to urinate at night.
The Correct Answer is C
Choice A reason: This is not the best response because it is alarmist and does not address the client's concern. The nurse should not assume that the client needs to have their medications adjusted or be admitted to the hospital without further assessment.
Choice B reason: This is not the best response because it is inaccurate and does not explain the link between urine retention and confusion. The nurse should not imply that the client is causing their own confusion by not drinking enough water.
Choice C reason: This is the best response because it is accurate and educates the client on the effects of dehydration on the body. The nurse should encourage the client to drink more fluids throughout the day and offer strategies to make it easier for them to access the bathroom at night.
Choice D reason: This is not the best response because it is irrelevant and does not address the client's dehydration. The nurse should not suggest that the client has a urinary tract infection without evidence or testing. The nurse should also not discourage the client from urinating at night, as this can lead to other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fried cheese is a food that the nurse will question on the tray for a client with acute gallbladder inflammation. Fried cheese is high in fat, which can trigger or worsen the symptoms of gallbladder disease. Fat can stimulate the contraction of the gallbladder, which can cause pain and inflammation if there are gallstones blocking the bile ducts.
Choice B reason: Green beans are not a food that the nurse will question on the tray for a client with acute gallbladder inflammation. Green beans are low in fat and high in fiber, which can help prevent or reduce the symptoms of gallbladder disease. Fiber can help lower the cholesterol levels in the bile, which can reduce the risk of gallstone formation.
Choice C reason: Grilled chicken breast is not a food that the nurse will question on the tray for a client with acute gallbladder inflammation. Grilled chicken breast is a lean protein source, which can provide essential amino acids for the client's health. Protein can also help maintain the muscle mass and strength of the client, who may have reduced appetite and weight loss due to gallbladder disease.
Choice D reason: Whole grain dinner roll is not a food that the nurse will question on the tray for a client with acute gallbladder inflammation. Whole grain dinner roll is a complex carbohydrate source, which can provide energy and fiber for the client. Carbohydrates can also help balance the acid-base status of the client, who may have metabolic acidosis due to impaired bile secretion and digestion.
Correct Answer is D
Explanation
Choice A reason: Mental alertness is not affected by the administration of hypertonic solutions. Hypertonic solutions are fluids that have a higher concentration of solutes than the blood. They draw water out of the cells and into the blood vessels, increasing the blood volume and osmolarity.
Choice B reason: Decreased pulse is not a result of administering hypertonic solutions too quickly. On the contrary, hypertonic solutions can increase the pulse rate as they increase the blood volume and pressure.
Choice C reason: Decreased blood pressure is not a consequence of administering hypertonic solutions too quickly. Hypertonic solutions can raise the blood pressure as they increase the blood volume and osmolarity.
Choice D reason: Fluid overload is the correct answer. Administering hypertonic solutions too quickly can cause fluid overload, which is a condition where the body has too much fluid in the blood vessels. This can lead to symptoms such as edema, dyspnea, crackles, and weight gain. Fluid overload can also cause heart failure, pulmonary edema, and cerebral edema.
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