The nurse is caring for an 80-year-old patient who is being admitted for treatment of gastroenteritis. What does the nurse recognize as the highest priority for this patient?

Risk for injury

Activity intolerance

Fluid volume deficit

Limited mobility

Answer and Explanation

The Correct Answer is C

Choice A reason: Risk for injury is a concern in elderly patients due to frailty, but it is not the highest priority in gastroenteritis. Fluid volume deficit from diarrhea and dehydration poses a greater immediate risk, as it can lead to hypotension, organ failure, or shock, requiring urgent rehydration to stabilize the patient.

Choice B reason: Activity intolerance may occur in elderly patients with gastroenteritis due to weakness from dehydration, but it is secondary to fluid volume deficit. Dehydration causes tachycardia, hypotension, and fatigue, which must be addressed first to restore hemodynamic stability. Activity intolerance is a consequence, not the primary concern, in this acute condition.

Choice C reason: Fluid volume deficit is the highest priority in gastroenteritis, especially in an elderly patient. Diarrhea causes significant water and electrolyte loss, leading to dehydration, hypotension, and risk of organ failure. Rapid rehydration with IV fluids or oral rehydration solutions is critical to prevent life-threatening complications like shock or renal failure.

Choice D reason: Limited mobility is a concern in elderly patients but is not the primary issue in gastroenteritis. Dehydration from diarrhea poses a more immediate threat, causing cardiovascular and renal complications. Mobility issues may exacerbate risks like falls, but fluid volume deficit is the acute, life-threatening priority requiring immediate intervention.

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Correct Answer is B

Explanation

Choice A reason: Cushing’s syndrome, caused by cortisol excess, leads to fluid retention and hypertension, not high urine output. Post-craniotomy, excessive urine output suggests pituitary dysfunction, not cortisol overproduction. Cushing’s does not cause polyuria; instead, it may reduce urine output due to water retention, making this diagnosis unlikely.

Choice B reason: Diabetes insipidus (DI) is likely post-craniotomy due to pituitary or hypothalamic damage, impairing antidiuretic hormone (ADH) secretion. This causes inability to concentrate urine, leading to excessive dilute urine output (e.g., 1,500 mL/hour). DI’s hallmark is polyuria, matching the patient’s symptoms, requiring urgent ADH replacement and fluid management.

Choice C reason: Adrenal crisis causes hypotension, hyponatremia, and reduced urine output due to aldosterone deficiency and dehydration. High urine output is not a feature, as adrenal insufficiency leads to volume depletion, not polyuria. Post-craniotomy, pituitary-related conditions like DI are more likely than adrenal dysfunction in this scenario.

Choice D reason: SIADH causes water retention due to excessive ADH, leading to low urine output and concentrated urine. The patient’s high urine output (1,500 mL/hour) is opposite to SIADH’s oliguria. Post-craniotomy, DI is more common due to pituitary injury, making SIADH an incorrect diagnosis for this presentation.

A. Glucose level of 500 mg/dL B. Ketosis C. Hypertension D. Plasma osmolarity of 350 mOsm/L

Correct Answer is D

Explanation

Choice A reason: A glucose level of 500 mg/dL is elevated but not specific to HHS, which typically involves glucose >600 mg/dL. Both DKA and HHS feature hyperglycemia, but HHS is distinguished by higher glucose and osmolarity without significant ketosis. This level alone does not confirm HHS over other hyperglycemic states.

Choice B reason: Ketosis is characteristic of DKA, not HHS. HHS involves extreme hyperglycemia and hyperosmolarity with minimal ketone production due to sufficient insulin to prevent ketogenesis but not hyperglycemia. The absence of significant ketosis distinguishes HHS, making this an incorrect indicator for this condition.

Choice C reason: Hypertension is not a defining feature of HHS. HHS causes dehydration from osmotic diuresis, often leading to hypotension, not hypertension. While stress responses may elevate blood pressure, it is not a diagnostic criterion. Hyperosmolarity and hyperglycemia are the hallmarks, making this choice irrelevant to HHS diagnosis.

Choice D reason: Plasma osmolarity of 350 mOsm/L is a key indicator of HHS, which is defined by extreme hyperglycemia (>600 mg/dL) and hyperosmolarity (>320 mOsm/L). Osmotic diuresis from glucose causes dehydration, elevating osmolarity, leading to neurological symptoms like confusion. This distinguishes HHS from DKA, confirming the diagnosis.

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The nurse is caring for an 80-year-old patient who is being admitted for treatment of gastroenteritis. What does the nurse recognize as the highest priority for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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