An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

Protein.

Hemoglobin.

White blood cell count

Sodium.

Answer and Explanation

The Correct Answer is D

A.   While protein levels are important in assessing overall nutritional status and can indicate conditions like malnutrition or liver disease, they are not the primary focus in the context of fever, dry mucous membranes, and skin turgor changes.
B.   Hemoglobin levels are crucial for assessing anemia and overall oxygen-carrying capacity of the blood. Although dehydration can potentially concentrate hemoglobin levels, it is not the primary laboratory value to monitor in the context of the acute symptoms
C.   The white blood cell count is important for diagnosing infections and understanding the body's response to illness. However, in this scenario, the primary concern is dehydration, which is not directly measured by WBC count. While an elevated WBC could indicate an infection contributing to the fever, it is not the primary laboratory value to monitor for fluid and electrolyte imbalances.
D.   Sodium is a key electrolyte that can be significantly affected by dehydration. Dry mucous membranes, inelastic skin turgor, and a fever suggest potential fluid loss and dehydration, which can lead to imbalances in sodium levels. Monitoring sodium levels is crucial because dehydration often results in elevated sodium concentrations (hypernatremia), which can have serious implications for the client’s health.

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Correct Answer is A

Explanation

A. This is a condition where the skin becomes hyperemic and hot after the application of heat. It's a sign of tissue damage and can lead to burns. Assessing for rebound phenomenon before applying a heating pad is crucial to prevent further injury.
B. While assessing range of motion can be helpful in determining the effectiveness of heat therapy, it's not the most important factor to consider before application.
C. Muscle strength and tone are not directly related to the risk of skin damage from heat therapy.
D. While neurosensory impairment can affect a client's ability to perceive heat and respond to pain, assessing for rebound phenomenon is a more direct way to evaluate the risk of skin damage.

A. Provide frequent rest periods for the client. B. Allow additional time to complete tasks. C. Place assistive devices within reach. D. Speak slowly and distinctly to the client.

Correct Answer is C

Explanation

A. Providing frequent rest periods is important for older adults, especially those who may be experiencing fatigue or have chronic conditions. However, this intervention, while supportive, is not always the most critical or directly related to creating a therapeutic environment in all situations.
B. Allowing additional time for tasks is crucial for older adults who may have slower cognitive or physical processes. This approach helps reduce stress and frustration, contributing to a more supportive and therapeutic environment.
C. Placing assistive devices within reach is essential for ensuring safety and promoting independence. It helps older adults perform tasks more easily and reduces the risk of falls or accidents. This intervention is crucial for creating a therapeutic environment as it directly impacts the client’s ability to manage their own care and environment effectively.
D. Speaking slowly and distinctly is important for effective communication, especially if the older adult has hearing or cognitive impairments. It helps ensure that the client understands instructions and information, which is fundamental for their safety and engagement in their care.

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An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is A

Explanation

When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

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