A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

A. Increased pulse rate:

This is a common manifestation of fluid overload. Excess fluid volume can lead to an increase in cardiac output, causing the heart to pump faster and resulting in an increased pulse rate.

B. Decreased blood pressure:

Fluid overload typically leads to increased blood volume, which can initially cause an increase in blood pressure. However, as fluid overload progresses, it can lead to fluid redistribution, venous congestion, and decreased systemic vascular resistance, ultimately resulting in decreased blood pressure.

C. Skeletal muscle weakness:

Skeletal muscle weakness is not a direct manifestation of fluid overload. It is more commonly associated with electrolyte imbalances, such as hypokalemia or hypomagnesemia, which can occur as a consequence of fluid shifts but are not specific to fluid overload itself.

D. Warm and pink skin:

Warm and pink skin is not typically associated with fluid overload. Instead, it is more indicative of adequate tissue perfusion and oxygenation. In fluid overload, skin changes may include edema, cool and clammy skin due to venous congestion, or signs of skin breakdown in areas of pressure.

E. Distended neck veins:

Distended neck veins, specifically jugular venous distention (JVD), are commonly seen in patients with fluid overload, especially if there is right-sided heart failure or increased central venous pressure. JVD is a result of increased venous return to the heart due to fluid accumulation.

A. A 60-year-old client with gastritis:

Gastritis is inflammation of the stomach lining and typically does not directly increase the risk of skin infections. However, if the gastritis is due to an underlying condition that affects the immune system, such as an autoimmune disorder, the client may have a slightly higher risk of infections, including skin infections, compared to a healthy individual of the same age. Overall, gastritis alone is not a significant risk factor for skin infections compared to the other options.

B. A 20-year-old client with a closed tibia fracture:

A closed tibia fracture refers to a broken shinbone that does not break the skin. While fractures themselves do not necessarily increase the risk of skin infections, they can indirectly contribute to infection risk if there are complications such as open wounds, surgical procedures, or prolonged immobilization. In this case, because the fracture is closed and presumably not complicated by open wounds or surgery, this client is not significantly prone to skin infections compared to the other options.

C. A 55-year-old client taking an ACE inhibitor:

ACE (angiotensin-converting enzyme) inhibitors are medications commonly used to treat conditions like high blood pressure and heart failure. While these medications can cause side effects like a dry cough or skin rash in some individuals, they do not directly increase the risk of skin infections. Unless the client experiences a severe allergic reaction or develops a rash that becomes infected, the use of ACE inhibitors alone is not a major risk factor for skin infections compared to the other options.

D. A 35-year-old client receiving chemotherapy:

Chemotherapy is a treatment for cancer that works by targeting rapidly dividing cells, including cancer cells but also affecting some healthy cells like those in the bone marrow responsible for producing white blood cells. As a result, chemotherapy can significantly weaken the immune system, leading to a higher risk of infections, including skin infections. Patients undergoing chemotherapy are particularly susceptible to bacterial, fungal, and viral infections due to their compromised immune response. Therefore, the 35-year-old client receiving chemotherapy is the most prone to skin infections among the options given due to their weakened immune system.