The nurse notices that an older adult’s urine is concentrated. Which step should the nurse implement next?
Evaluate the medication list
Review laboratory reports
Increase oral fluid intake
Determine fluid volume status
The Correct Answer is D
Choice A reason: Evaluating the medication list is a possible step that the nurse can take, as some medications can affect urine concentration or cause dehydration. However, it is not the first step that the nurse should implement, as it does not address the immediate problem of fluid balance.
Choice B reason: Reviewing laboratory reports is another possible step that the nurse can take, as some laboratory tests can indicate the level of hydration or kidney function of the patient. However, it is not the first step that the nurse should implement, as it does not provide a direct assessment of fluid status.
Choice C reason: Increasing oral fluid intake is a potential intervention that the nurse can suggest, as it can help to dilute the urine and prevent dehydration. However, it is not the first step that the nurse should implement, as it may not be appropriate for some patients who have fluid restrictions or other medical conditions.
Choice D reason: Determining fluid volume status is the first step that the nurse should implement, as it can help to identify the cause and severity of urine concentration and guide further actions. The nurse can assess the patient's fluid intake and output, weight, blood pressure, pulse, skin turgor, mucous membranes, and urine specific gravity to determine fluid volume status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because baroreceptor function diminishes with age, and this can affect the regulation of blood pressure and heart rate. Baroreceptors are sensory receptors that detect changes in blood pressure and send signals to the brain to adjust the heart rate and blood vessel tone accordingly. When a person exercises, the blood pressure and heart rate increase to meet the increased oxygen demand of the muscles. When a person stops exercising, the blood pressure and heart rate should decrease gradually to return to the resting state. However, if a person does not cool down properly after exercising, the blood pressure and heart rate can drop suddenly, causing dizziness, fainting, or cardiac arrhythmias. This is especially true for older adults, whose baroreceptors are less sensitive and responsive to blood pressure changes. Therefore, the nurse should instruct the older man to cool down after exercising to prevent these complications.
Choice B reason: This is incorrect because sensory perception diminishes with age, but this is not related to the importance of cooling down after exercising. Sensory perception is the ability to perceive stimuli from the environment, such as sight, hearing, touch, smell, or taste. Sensory perception can decline with age due to various factors, such as age-related changes in the sensory organs, nerve damage, or diseases. This can affect the quality of life, communication, and safety of older adults, but it does not explain why cooling down after exercising is important.
Choice C reason: This is incorrect because cardiac output diminishes with age, but this is not related to the importance of cooling down after exercising. Cardiac output is the amount of blood pumped by the heart per minute, and it depends on the heart rate and the stroke volume. Cardiac output can decline with age due to various factors, such as age-related changes in the heart muscle, valves, or arteries, or diseases. This can affect the ability of the heart to meet the oxygen demand of the body, especially during exercise, but it does not explain why cooling down after exercising is important.
Choice D reason: This is incorrect because mobility capacity decreases with age, but this is not related to the importance of cooling down after exercising. Mobility capacity is the ability to move and perform physical activities, such as walking, climbing stairs, or lifting objects. Mobility capacity can decrease with age due to various factors, such as age-related changes in the muscles, bones, or joints, or diseases. This can affect the functional status, independence, and well-being of older adults, but it does not explain why cooling down after exercising is important.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Asking about the circumstances behind the fall(s) can help you identify the possible risk factors and causes of the fall(s), such as environmental hazards, medications, chronic conditions, or acute illnesses. Asking about the circumstances can also help you determine the severity and urgency of the situation, and whether the client needs further evaluation or referral.
Choice B reason: Assessing for any injuries the client might have is important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any life-threatening or serious injuries that may require immediate attention. Assessing for injuries is part of the comprehensive fall risk assessment that should be done after the initial screening.
Choice C reason: Evaluating the client for gait and balance is also important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any underlying medical conditions that may affect the client's gait and balance. Evaluating gait and balance is part of the comprehensive fall risk assessment that should be done after the initial screening.
Choice D reason: Asking about the history or frequency of falls can help you assess the client's fall risk and identify any patterns or trends in the client's fall history. Asking about the history or frequency of falls can also help you tailor the appropriate interventions and prevention strategies for the client.
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