The nurse is assessing an elder client for hydration. What is the best determination of hydration in this client?
Serum sodium levels
BUN
Urine osmolality
Urine color
The Correct Answer is C
Choice A reason: Serum sodium levels are not the best determination of hydration in this client, as they can be affected by other factors, such as fluid intake, fluid loss, kidney function, or medication use. Serum sodium levels can be normal, high, or low in a dehydrated or overhydrated client, depending on the cause and type of the fluid imbalance.
Choice B reason: BUN stands for blood urea nitrogen, which is a waste product of protein metabolism that is excreted by the kidneys. BUN is not the best determination of hydration in this client, as it can be influenced by other factors, such as protein intake, liver function, or muscle breakdown. BUN can be high or low in a dehydrated or overhydrated client, depending on the cause and type of the fluid imbalance.
Choice C reason: Urine osmolality is the best determination of hydration in this client, as it measures the concentration of solutes in the urine, which reflects the ability of the kidneys to adjust the urine output according to the fluid status. Urine osmolality can indicate the degree of dehydration or overhydration in a client, as it increases or decreases in response to the fluid balance.
Choice D reason: Urine color is not the best determination of hydration in this client, as it can be affected by other factors, such as food, medication, or infection. Urine color can be dark or light in a dehydrated or overhydrated client, depending on the cause and type of the fluid imbalance.
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Correct Answer is D
Explanation
Choice A reason: Older adult’s self-report is not the most helpful tool, as it may not be reliable or consistent in older adults, especially if they have cognitive impairment, communication difficulties, or cultural barriers. Older adults may also underreport or overreport their pain due to fear, stoicism, or expectations.
Choice B reason: FPS-R (Faces Pain Scale-Revised) is not the most helpful tool, as it may not be suitable or valid for older adults, especially if they have visual impairment, facial paralysis, or dementia. FPS-R is a pictorial scale that uses six facial expressions to represent different levels of pain intensity, from 0 (no pain) to 10 (very much pain).
Choice C reason: Pain medication frequency is not the most helpful tool, as it may not reflect the actual pain level or the effectiveness of the pharmacotherapy. Pain medication frequency may vary depending on the type, dose, route, and duration of the medication, as well as the individual response and tolerance of the older adult.
Choice D reason: Older adult's pain diary is the most helpful tool, as it can provide a comprehensive and longitudinal record of the pain experience, including the location, intensity, quality, frequency, duration, triggers, relievers, and impact of the pain. A pain diary can also help track the use and response of the comfort measures, activity, and pharmacotherapy, and identify the patterns and trends of the pain.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the most helpful tool for the nurse to use.
Correct Answer is A
Explanation
Choice A reason: 2400 mL/day is the recommended fluid intake for older adults, according to the National Council on Aging. This amount can help prevent dehydration, which can cause various health problems in older adults, such as urinary tract infections, constipation, confusion, and falls.
Choice B reason: 1920 mL/day is not enough fluid intake for older adults, as it is below the minimum requirement of 6-8 glasses of fluid a day, according to Age UK. This amount can increase the risk of dehydration and its complications in older adults.
Choice C reason: 3000 mL/day is too much fluid intake for older adults, as it exceeds the maximum limit of 10 glasses of fluid a day, according to The Conversation. This amount can cause overhydration, which can lead to hyponatremia, a condition where the sodium level in the blood becomes too low. Hyponatremia can cause symptoms such as nausea, headache, confusion, and seizures.
Choice D reason: 1500 mL/day is not enough fluid intake for older adults, as it is half of the recommended amount of 2400 mL/day, according to the National Council on Aging. This amount can increase the risk of dehydration and its complications in older adults.
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