The community health nurse is performing a home visit for a 74-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. The client states to stop drinking water early in the day because it's just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response?

You need to have your medications adjusted so you need to be admitted to the hospital for a complete workup.

You build up too much urine in your bladder, which can cause you to get confused.

Dehydration can cause changes that can result in confusion, so let's try to increase your fluid intake.

Urinary tract infections are common and can cause confusion, so it's important not to urinate at night.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the best response because it is alarmist and does not address the client's concern. The nurse should not assume that the client needs to have their medications adjusted or be admitted to the hospital without further assessment.

Choice B reason: This is not the best response because it is inaccurate and does not explain the link between urine retention and confusion. The nurse should not imply that the client is causing their own confusion by not drinking enough water.

Choice C reason: This is the best response because it is accurate and educates the client on the effects of dehydration on the body. The nurse should encourage the client to drink more fluids throughout the day and offer strategies to make it easier for them to access the bathroom at night.

Choice D reason: This is not the best response because it is irrelevant and does not address the client's dehydration. The nurse should not suggest that the client has a urinary tract infection without evidence or testing. The nurse should also not discourage the client from urinating at night, as this can lead to other complications.

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Correct Answer is C

Explanation

Choice A reason: This is not a correct sign of hypervolemia. Increased thirst and dry mucous membranes are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.

Choice B reason: This is not a correct sign of hypervolemia. Low blood pressure and increased heart rate are signs of hypovolemic shock, which can occur due to severe fluid loss or hemorrhage.

Choice C reason: This is a correct sign of hypervolemia. Difficulty breathing and weight gain are signs of fluid overload, which can occur due to excessive fluid retention or impaired cardiac function. Difficulty breathing can be caused by pulmonary edema, which is the accumulation of fluid in the lungs. Weight gain can be caused by the increase in total body fluid.

Choice D reason: This is not a correct sign of hypervolemia. Dry cough and poor skin turgor are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.

A. You need to have your medications adjusted so you need to be admitted to the hospital for a complete workup. B. You build up too much urine in your bladder, which can cause you to get confused. C. Dehydration can cause changes that can result in confusion, so let's try to increase your fluid intake. D. Urinary tract infections are common and can cause confusion, so it's important not to urinate at night.

Correct Answer is C

Explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing early signs of hypervolemia with a patient admitted with congestive heart failure. Which signs should the nurse include in their teaching?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of extreme abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?

A nurse is caring for several patients with fluid imbalances. A priority nursing intervention for a client with hypervolemia involves which of the following?

A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

The nurse provides care for several clients who have obesity. Which client's obesity is most likely to resolve with medication?

A nurse in the emergency department is caring for a client who sustained a head injury and hypovolemia. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse before calling the physician to clarify the order?

A nurse is caring for an adult client who has a fever of 39.4°C (103°F) and is receiving 0.9% sodium chloride IV at 125 mL/hr. Over the last hour, the nurse notes that the client's urine output is 20 mL. The nurse should report this finding to the provider and anticipate a prescription for what?

A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?

A client is suspected to have diverticulosis without symptoms of diverticulitis. Which diagnostic test should the nurse prepare the client to undergo?