The nurse caring for a client diagnosed with dehydration recognizes that which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Administering diuretics as ordered

Providing good skin and mouth care

Monitoring intake and output

Obtaining daily weights

Answer and Explanation

Correct Answer : B,C,D

A. Administering diuretics as ordered: This option is not appropriate for dehydration management. Diuretics are medications that increase urine output and are typically used to treat fluid overload rather than dehydration. Administering diuretics to a dehydrated client could exacerbate fluid loss and worsen the condition.

B. Providing good skin and mouth care: This is a suitable intervention for managing dehydration. Dehydration can lead to dry skin and mucous membranes. Providing good skin care, including moisturizing, can help prevent skin breakdown. Additionally, ensuring adequate oral hygiene and providing moist mouth swabs can alleviate discomfort associated with dry mouth.

C. Monitoring intake and output: This is an essential nursing intervention for managing dehydration. Monitoring the client's fluid intake and output allows the nurse to assess the balance between fluid intake and loss. Decreased urine output is a common sign of dehydration, while monitoring intake helps ensure the client is receiving adequate fluids.

D. Obtaining daily weights: This is an appropriate nursing intervention for managing dehydration. Daily weights can help assess changes in fluid balance. A sudden increase in weight may indicate fluid retention, while a decrease may indicate ongoing fluid loss, both of which are important to monitor in dehydration.

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Correct Answer is B

Explanation

A. Functional incontinence: Functional incontinence occurs when a person has difficulty reaching the toilet due to physical or cognitive impairments. Cloudy, amber urine with an unpleasant odor is not indicative of functional incontinence.

B. Urinary tract infection (UTI): Cloudy, amber urine with an unpleasant odor is a common symptom of a UTI. UTIs often cause changes in urine color, odor, and clarity due to the presence of bacteria and inflammatory cells in the urine.

C. Ketone bodies in the urine: Ketones in the urine can occur in conditions such as uncontrolled diabetes or during periods of fasting. However, cloudy, amber urine with an unpleasant odor is more indicative of a UTI rather than the presence of ketones.

D. Nocturia: Nocturia refers to waking up during the night to urinate. While it may be associated with certain urinary conditions, it does not directly correlate with the appearance and odor of the urine.

A. sexually transmitted infections. B. the need for contraception. C. facts vs. myths about sex. D. hormonally-induced decrease in vaginal lubrication. E. erectile dysfunction.

Correct Answer is ["A","B","C"]

Explanation

A. Sexually transmitted infections (STIs): Assessing the client's knowledge of STIs is crucial following the initiation of sexual activity to ensure understanding of risks and preventive measures. It enables the nurse to provide education on STI transmission, symptoms, prevention methods (such as condom use), and the importance of regular STI screening.

B. The need for contraception: Assessing the client's understanding of contraception is essential to prevent unintended pregnancies. The nurse can explore the client's knowledge of contraceptive methods, their effectiveness, correct usage, and availability. Providing education on contraceptive options empowers the client to make informed decisions about protecting their sexual health.

C. Facts vs. myths about sex: Assessing the client's understanding of facts and myths surrounding sex helps identify any misconceptions or gaps in knowledge. This allows the nurse to provide accurate information about sexual anatomy, physiology, reproductive health, and healthy sexual practices. Addressing myths promotes sexual health literacy and reduces the risk of misinformation influencing behavior.

D. Hormonally-induced decrease in vaginal lubrication: Assessing hormonal changes affecting vaginal lubrication is less relevant in this context, as it primarily applies to physiological changes in older individuals or those experiencing hormonal fluctuations due to menopause or medical conditions. It is not typically a concern immediately following a first sexual experience in adolescence.

E. Erectile dysfunction: Assessing knowledge of erectile dysfunction is more pertinent in males and is typically not a primary concern immediately following a first sexual experience for a female client. While it is valuable to address sexual health comprehensively, focusing on topics directly relevant to the client's situation is paramount for effective assessment and education.

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The nurse caring for a client diagnosed with dehydration recognizes that which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client's urine is cloudy, amber, and has an unpleasant odor. The nurse should make the inference that the client may have:

Correct Answer is B

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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