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 C
Explanation
Choice A: This is incorrect because blood glucose 98 mg/dL is within the normal range of 70 to 110 mg/dL. The nurse does not need to notify the provider for this value.
Choice B: This is incorrect because BUN 18 mg/dL is within the normal range of 10 to 20 mg/dL. The nurse does not need to notify the provider for this value.
Choice C: This is correct because hemoglobin 8.6 g/dL is below the normal range of 12 to 18 g/dL. The nurse should notify the provider for this value as it indicates anemia, which can be caused by blood loss during surgery or impaired bone marrow function.
Choice D: This is incorrect because potassium 3.5 mEq/L is within the normal range of 3.5 to 5.0 mEq/L. The nurse does not need to notify the provider for this value.
Correct Answer is C
Explanation
Choice C: Recommending consumption of cold items is an action that the nurse should take to help manage stomatitis, which is inflammation and ulceration of the oral mucosa. Cold items can help soothe the irritation and reduce swelling.
Choice a is not correct because providing an alcohol-based mouthwash is an action that the nurse should avoid when caring for a client who has stomatitis. Alcohol can dry and irritate the oral mucosa and worsen the condition.
Choice b is not correct because minimizing the use of gravies and sauces is not an action that the nurse should take to help manage stomatitis. Gravies and sauces can help moisten dry foods and make them easier to swallow for a client who has stomatitis.
Choice d is not correct because discouraging drinking with a straw is not an action that the nurse should take to help manage stomatitis. Drinking with a straw can help prevent contact between fluids and sore areas of the mouth and reduce pain for a client who has stomatitis.
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