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)
Category | ATI |
Release date | 2021-09-14 |
Pages | 20 |
Language | English |
Comments | 0 |
Sales | 0 |
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