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 D
Explanation
Choice A reason: Cheese is a dairy product that contains protein and fat but little or no fiber.
Choice B reason: Eggs are an animal product that contains protein and fat but no fiber.
Choice C reason: Yogurt is a dairy product that contains protein and calcium but little or no fiber.
Choice D reason: Pears are a fruit that contains dietary fiber, which can help prevent constipation, lower cholesterol levels, and regulate blood sugar levels.
Correct Answer is B
Explanation
Choice A reason: Providing the client with small-handled adaptive utensils is not necessary for a visually impaired client. The client may prefer to use their own utensils or regular ones that they are familiar with.
Choice B reason: Describing the food placement as though the plate were a clock is a helpful technique to orient the client to their meal and avoid spills or accidents. The nurse should also ask the client about their preferences and needs before serving the food.
Choice C reason: Discouraging conversations during the client's mealtime is not appropriate for a visually impaired client. The nurse should encourage social interactions and respect the client's dignity and autonomy.
Choice D reason: Arranging for an assistive personnel to feed the client is not indicated for a visually impaired client. The nurse should promote the client's independence and self-care abilities as much as possible.
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