1. The nurse observes skin tenting on the back of the older adult client’s hand. Which action by the nurse is most appropriate?

a.            Notify the physician.

b.            Examine dependent body areas.

c.             Assess turgor on the client’s forehead.

d.            Document the finding and continue to monitor.

ANS: C

Skin turgor cannot be accurately assessed on an older adult client’s hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment)

2. The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what potential complication?

a.            Fluid retention

b.            Hyperkalemia

c.             Hyponatremia

d.            Hypervolemia

ANS: B

Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client’s risk for excessive water loss and increased potassium reabsorption. The client would not be at risk for overhydration or sodium imbalance.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

3. Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L?

a.            Measuring urine output

b.            Measuring abdominal girth

c.             Monitoring fluid intake

d.            Comparing radial versus apical pulses

ANS: A

The blood osmolarity is low. The client could be dehydrated (hypo-osmolar dehydration) or overhydrated with dilution of blood solute. The most sensitive noninvasive indicator of circulation adequacy is urine output. Measuring abdominal girth, comparing pulses, and monitoring fluid intake would not be accurate assessment techniques for this client.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

4. Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte imbalances?

a.            “My skin is always so dry, especially here in the Southwest.”

b.            “I often use a glycerin suppository for constipation.”

c.             “I don’t drink liquids after 5 PM so I don’t have to get up at night.”

d.            “In addition to coffee, I drink at least one glass of water with each meal.”

ANS: C

Restricting fluids without a medical reason can lead to dehydration. Many older clients believe that restricting fluids will prevent incontinence and reduce the number of times that they wake up during the night. The increased osmolarity of the urine in response to reducing fluid intake increases irritation of the bladder and sphincter, increasing the sensation of needing to urinate. The other statements do not indicate practices that could potentially lead to dehydration.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

5. A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective?

a.            Chinese take-out, including steamed rice

b.            A grilled cheese sandwich with tomato soup

c.             Slices of ham and cheese on whole grain crackers

d.            A chicken leg, one slice of bread with butter, and steamed carrots

ANS: D

Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The Chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food—a category of foods often high in sodium.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

6. A client is on a potassium-restricted diet. Which protein choice by the client indicates a good understanding of the dietary regimen?

a.            1% or 2% milk

b.            Grilled salmon

c.             Poached eggs

d.            Baked chicken

ANS: C

Eggs contain few cells and have one of the lowest potassium contents among high-protein foods. Meat and fish have cells that contain large amounts of potassium. Dairy products are also high in potassium.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

7. Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?

a.            “I am often cold and need to wear a sweater.”

b.            “I seem to urinate more when I drink coffee.”

c.             “In the summer, I feel thirsty more often.”

d.            “My rings seem to be tighter this week.”

ANS: D

A change in ring size over a relatively short period of time may indicate a change in body fluid amount or distribution rather than a change in body fat. The other statements are not indicators of a fluid or electrolyte imbalance.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment)

8. Which client is at greatest risk for dehydration?

a.            Younger adult client on bedrest

b.            Older adult client receiving hypotonic IV fluid

c.             Younger adult client receiving hypertonic IV fluid

d.            Older adult client with cognitive impairment

ANS: D

Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 174

TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Assessment)

9. Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause?

a.            “Do you take diuretics, or ‘water pills’?”

b.            “What do you normally eat over a day’s time?”

c.             “How many bowel movements do you have daily?”

d.            “Have you been diagnosed with diabetes mellitus?”

ANS: A

Misuse or overuse of diuretics is a common cause of isotonic dehydration. The other statements are not indicative of causes of isotonic dehydration.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

10. Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion?

a.            Measuring intake and output every four hours

b.            Applying oxygen by mask or nasal cannula

c.             Increasing the IV flow rate to 250 mL/hr

d.            Placing the client in a high Fowler’s position

ANS: B

Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

11. A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition?

a.            “I must drink a quart of water or other liquid each day.”

b.            “I will weigh myself each morning before I eat or drink.”

c.             “I will use a salt substitute when making and eating my meals.”

d.            “I will not drink liquids after 6 PM so I won’t have to get up at night.”

ANS: B

Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

12. What intervention is most important to teach the client about identifying the onset of dehydration?

a.            Measuring abdominal girth

b.            Converting ounces to milliliters

c.             Obtaining and charting daily weight

d.            Selecting food items with high water content

ANS: C

Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Obtaining and charting accurate daily weights is the most sensitive and cost-effective way of monitoring fluid balance in the home. The other options would not be useful for early detection of dehydration.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Implementation)