An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

"Have you experienced hypoglycemia recently?"

"Are you currently taking any diuretic medications?"

"What types of foods do you purchase?"

"What kind of over-the-counter dietary supplements do you take?"

Answer and Explanation

The Correct Answer is B

A. Hypoglycemia is not a primary cause of dehydration, though it can contribute to other symptoms.
B. Asking about diuretic medications is correct because diuretics increase urine output, which can lead to fluid loss and dehydration, particularly in older adults who may not adequately compensate with fluid intake.
C. The types of food purchased can influence hydration status but are not a primary factor in acute dehydration.
D. Over-the-counter supplements may have effects on hydration, but they are not the most immediate concern when assessing risk factors for dehydration.

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Correct Answer is C

Explanation

A. Drinking fluids before and after meals but not during meals is incorrect. Clients with dysphagia may require thickened liquids and should sip fluids as needed to facilitate swallowing.
B. Sitting with the head of the bed at a 45-degree angle is incorrect. Clients with dysphagia should be positioned at a 90-degree angle (fully upright) during meals to reduce the risk of aspiration.
C. Thoroughly chewing small amounts of food with each mouthful is correct. Clients with dysphagia should eat slowly, take small bites, and chew food thoroughly to prevent choking and aspiration.
D. Temporomandibular joint pain is not a common issue associated with dysphagia following a stroke. The primary concern is the risk of aspiration.

A. Palpate for pitting edema. B. Assess for oral temperature. C. Inspect the oral mucosa. D. Auscultate adventitious lung sounds.

Correct Answer is C

Explanation

A. Palpating for pitting edema assesses for fluid overload, but this client is more likely experiencing fluid deficit rather than retention.
B. Assessing oral temperature is important, but there is no indication of infection or fever contributing to fluid loss in this scenario.
C. Inspecting the oral mucosa is correct because the client's total intake (1,245 mL) is significantly lower than their total output (1,928 mL), indicating a negative fluid balance. Signs of dehydration, such as dry oral mucosa, should be assessed first.
D. Auscultating adventitious lung sounds is relevant for fluid overload but is not the priority in a case of fluid deficit.

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An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

What is the primary purpose of a nursing health assessment?

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