A nurse is performing an admission assessment on an older patient who presented with a high fever and cough, reduced oral intake for 3 days, and lower extremity weakness. The patient has sunken eyes, and the patient’s skin turgor over the sternum is poor. The nurse suspects that the patient is dehydrated. Which of the following are indicators of dehydration in this patient? (Select all that apply.)
Sunken eyes
Lower extremity weakness
High fever
Cough
Correct Answer : A,B
Choice A reason: Sunken eyes are a sign of dehydration because the fluid loss causes the eyes to lose their shape and appear hollow. This is especially noticeable in older adults who have less fat and muscle around the eyes.
Choice B reason: Lower extremity weakness is a sign of dehydration because the fluid loss affects the blood volume and circulation, leading to reduced oxygen and nutrient delivery to the muscles. This can cause muscle fatigue, cramps, and weakness.
Choice C reason: High fever is not a sign of dehydration, but rather a possible cause of dehydration. Fever increases the body temperature and metabolic rate, which leads to increased sweating and fluid loss. However, fever itself does not indicate dehydration, unless it is accompanied by other signs and symptoms.
Choice D reason: Cough is not a sign of dehydration, but rather a possible cause of dehydration. Coughing can cause fluid loss through the respiratory tract, especially if it is productive or associated with vomiting. However, cough itself does not indicate dehydration, unless it is accompanied by other signs and symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: This is a correct answer because Alzheimer's disease affects the brain cells and causes them to degenerate and die. This leads to a gradual decline in cognitive abilities, such as memory, language, reasoning, and problem-solving.
Choice B reason: This is a correct answer because Alzheimer's disease interferes with the daily activities and routines of the affected person. They may experience a decline from their previous level of functioning, such as forgetting appointments, misplacing items, or getting lost.
Choice C reason: This is an incorrect answer because easily frustrated is not a specific outcome of the early stage of Alzheimer's disease. Although some people with Alzheimer's disease may become frustrated, irritated, or angry due to their cognitive impairment, this is not a universal or diagnostic symptom.
Choice D reason: This is a correct answer because Alzheimer's disease affects the short-term memory first, causing the person to forget recent events, conversations, or names. This is called mild memory loss, and it is one of the most common signs of the early stage of Alzheimer's disease.
Choice E reason: This is a correct answer because Alzheimer's disease affects the frontal lobe of the brain, which is responsible for executive functions, such as planning, organizing, decision-making, and judgement. This leads to impaired judgement, such as making poor financial choices, neglecting personal hygiene, or acting inappropriately.
Correct Answer is ["A","B","E","F"]
Explanation
Choice A reason: Diaphoresis is a common symptom of hypoglycemia, as the body tries to increase blood flow and release adrenaline to raise blood sugar levels. The client may notice sweating on the face, palms, or underarms.
Choice B reason: Anxiety is a common symptom of hypoglycemia, as the low blood sugar affects the brain and nervous system. The client may feel nervous, restless, or fearful.
Choice C reason: Tachycardia is not a reliable symptom of hypoglycemia for this client, as he is taking metoprolol, a beta-blocker that lowers the heart rate. Metoprolol can mask the signs of hypoglycemia, such as palpitations, tremors, and increased heart rate.
Choice D reason: Impaired vision is not a reliable symptom of hypoglycemia for this client, as he is an older adult who may have other eye problems, such as cataracts, glaucoma, or macular degeneration. Impaired vision can also be caused by other factors, such as fatigue, stress, or medication side effects.
Choice E reason: Confusion is a common symptom of hypoglycemia, as the low blood sugar affects the brain and cognitive function. The client may have difficulty thinking clearly, remembering things, or making decisions.
Choice F reason: Dizziness is a common symptom of hypoglycemia, as the low blood sugar affects the balance and coordination. The client may feel lightheaded, faint, or unsteady.
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