A nurse is caring for an older client on a medical-surgical unit.Which of the following interventions should be included in the plan of care?
Monitor the client’s hydration status.
Encourage the client to engage in physical activities.
Administer medications as prescribed.
Educate the client on dietary needs.
The Correct Answer is A
Choice A rationale
Monitoring the client’s hydration status is critical for older adults, especially those on a medical-surgical unit, to prevent dehydration, which can lead to serious complications such as renal impairment, confusion, and electrolyte imbalance.
Choice B rationale
Encouraging physical activities is beneficial but is not always feasible or safe for all older clients, especially those with certain medical conditions or mobility limitations.
Choice C rationale
Administering medications as prescribed is essential but is a standard practice for all clients and not specific to older adults' unique needs.
Choice D rationale
Educating the client on dietary needs is important but secondary to monitoring hydration, which addresses more immediate physiological needs and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Metastatic bone cancer does not typically result in an increase in platelet count. Platelets are involved in blood clotting, and their levels are not usually affected by bone metastases.
Choice B rationale
Calcium levels are often increased in clients with metastatic bone cancer due to the breakdown of bone tissue releasing calcium into the bloodstream.
Choice C rationale
Absolute neutrophil count (ANC) is not typically increased in metastatic bone cancer. ANC levels are more directly related to infections and bone marrow function.
Choice D rationale
White blood cell (WBC) count is not typically increased in metastatic bone cancer. Elevated WBC levels are more commonly associated with infection or inflammation.
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Tachycardia: Heatstroke often leads to an elevated heart rate due to the body's attempt to cool down and compensate for increased body temperature. The heart rate of 120 beats per minute noted in the client is consistent with tachycardia.
Choice B rationale:
Hallucinations: While confusion and disorientation are common symptoms of heatstroke, hallucinations are not typical findings associated with heatstroke. Therefore, this is not a consistent finding for this diagnosis.
Choice C rationale:
Skin is hot, dry: One of the hallmark signs of heatstroke is hot, dry skin, which results from the body's inability to regulate its temperature effectively. The client's skin being hot to the touch and dry aligns with this characteristic.
Choice D rationale:
Bradycardia: This is characterized by a slower than normal heart rate. Since the client presents with a heart rate of 120 beats per minute, which indicates tachycardia, bradycardia is not a finding consistent with heatstroke.
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