The nurse is caring for an older adult client who has an infection and a fever of 38°C (100.4°F).
The nurse should monitor the client for which of the following complications?
Dehydration
Hypothermia
Seizures
Delirium
The Correct Answer is D
The correct answer is D.
Delirium.
The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.
Delirium can affect the client’s cognition, attention, orientation, memory, and behavior. It can also increase the risk of falls, complications, and mortality.
Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.
Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature. Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.
Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.
Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure. Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.
Choice C is wrong because seizures are not a common complication of fever in older adults.
Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.
Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.
Fever-induced seizures are more likely to occur in young children than in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
These interventions are appropriate for reducing social isolation in older adult clients who live in a long-term care facility because they provide opportunities for social interaction, support, comfort and familiarity.
Choice A is correct because group activities such as games, music, art or exercise can foster a sense of belonging, enjoyment and engagement among older adults.Group activities can also improve physical and mental health, cognitive function and well-being.
Choice B is correct because encouraging family members or volunteers to visit or call the clients regularly can enhance the quality and quantity of social relationships, which can reduce loneliness and isolation.Family members or volunteers can also provide emotional support, companionship and practical assistance to the clients.
Choice C is correct because creating a homelike environment that promotes comfort, safety and privacy can increase the clients’ satisfaction, autonomy and dignity.A homelike environment can also facilitate social interactions among the clients and the staff by providing common areas, personal belongings and familiar objects.
Choice D is correct because assigning consistent staff members who are familiar with the clients’ needs and preferences can improve the continuity and quality of care, as well as the trust and rapport between the clients and the staff.Consistent staff members can also recognize and respond to the clients’ social needs and preferences, and provide personalized interventions.
Choice E is incorrect because providing feedback or recognition for the clients’ achievements or contributions may not be effective in reducing social isolation, unless it is combined with other interventions that promote social interaction and support.Feedback or recognition alone may not address the underlying causes of social isolation, such as lack of meaningful relationships, low self-esteem or poor health.
Normal ranges for social isolation and loneliness are difficult to define, as they depend on various factors such as individual characteristics, cultural norms and measurement tools.However, some indicators of social isolation include having few or no social contacts, participating in few or no social activities, feeling disconnected from others or society, and having low levels of perceived social support.Some indicators of loneliness include feeling unhappy about one’s social situation, feeling left out or unwanted, lacking companionship or intimacy, and having low levels of perceived belongingness or connectedness.
Correct Answer is D
Explanation
The correct answer is D.
Decreased mental status.Dehydration in elderly people can cause confusion, disorientation, or drowsiness due to the loss of water and electrolytes from the body.
These symptoms can affect the cognitive function and alertness of the client.Dehydration can also lead to complications such as kidney problems, electrolyte imbalances, or low blood pressure.
Choice A is wrong because increased skin turgor is not a sign of dehydration.
Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled.Dehydration causes decreased skin turgor, meaning the skin stays tented or wrinkled after being pinched.
Choice B is wrong because decreased pulse rate is not a sign of dehydration.Dehydration causes increased pulse rate, as the heart has to work harder to pump blood to the vital organs when there is less fluid in the body.
Choice C is wrong because increased urine output is not a sign of dehydration.Dehydration causes decreased urine output, as the kidneys try to conserve water and produce more concentrated urine.
The urine may also be darker in color than normal.
Normal ranges for fluid intake and output vary depending on age, weight, activity level, and health status.
However, a general guideline is to drink at least eight 8-ounce glasses of water per day and produce at least 30 mL of urine per hour.
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