A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated?
Recent onset of confusion
Cool, clammy skin
Decrease in pulse rate
Increase in blood pressure
The Correct Answer is A
Choice A: This is correct. Dehydration can cause electrolyte imbalance and affect the brain function, leading to confusion, dizziness, or lethargy.
Choice B: This is incorrect. Cool, clammy skin is a sign of shock, not dehydration. Dehydration can cause dry, warm skin.
Choice C: This is incorrect. Decrease in pulse rate is a sign of bradycardia, not dehydration. Dehydration can cause increase in pulse rate as the body tries to compensate for the low blood volume.
Choice D: This is incorrect. Increase in blood pressure is a sign of hypertension, not dehydration. Dehydration can cause decrease in blood pressure as the blood volume drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: This is incorrect because feeling bloated after the procedure is not a reason to call the doctor. Feeling bloated after a colonoscopy is normal due to air being introduced into the colon during the procedure. The client can relieve bloating by passing gas or walking.
Choice B: This is correct because making arrangements for a ride home indicates an understanding of the procedure. The client will receive sedation during a colonoscopy, which can impair their judgment and coordination. The client should not drive or operate machinery until fully recovered from sedation.
Choice C: This is incorrect because eating a light breakfast the morning of the procedure indicates a lack of understanding of the procedure. The client should have nothing by mouth after midnight before a colonoscopy, unless instructed otherwise by the provider. The client should follow a clear liquid diet and take bowel preparation agents as prescribed before the procedure.
Choice D: This is incorrect because having a sore throat from the breathing tube indicates a lack of understanding of the procedure. The client will not have a breathing tube during a colonoscopy, as it does not involve intubation or ventilation. The client may have a mouth guard or bite block to protect their teeth and prevent biting on the endoscope.
Correct Answer is A
Explanation
Choice A: This is correct because suction equipment is essential for clearing the airway of secretions or vomitus during or after a seizure. The nurse should have suction equipment ready and accessible at the client's bedside at all times.
Choice B: This is incorrect because backboard is not needed for a client who has a seizure disorder. Backboard is used for immobilizing the spine in case of a suspected spinal injury.
Choice C: This is incorrect because padded tongue blades are not recommended for a client who has a seizure disorder. Padded tongue blades can cause injury to the teeth, gums, or tongue if inserted during a seizure. The nurse should never force anything into the mouth of a client who is having a seizure.
Choice D: This is incorrect because wrist restraints are not indicated for a client who has a seizure disorder. Wrist restraints can cause injury or skin breakdown if applied during a seizure. The nurse should never restrain or restrict the movements of a client who is having a seizure.
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