The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?
Drink more fluids in the late evening
Increase fluids if your mouth feels dry
If you feel confused, you need to drink more caffeine
More fluids are needed if you feel full
The Correct Answer is B
Choice A reason: This statement is false. Drinking more fluids in the late evening can cause nocturia, which is the need to urinate frequently at night. This can disrupt the sleep cycle and increase the risk of falls.
Choice B reason: This statement is true. Dry mouth is a sign of dehydration and indicates the need for more fluid intake. Older adults may have reduced thirst sensation and may not drink enough fluids throughout the day.
Choice C reason: This statement is false. Caffeine is a diuretic, which means it increases urine output and can worsen dehydration. Confusion is a symptom of dehydration and requires immediate medical attention.
Choice D reason: This statement is false. Feeling full is not a reliable indicator of hydration status. Older adults may have decreased appetite and gastric motility, which can make them feel full even when they are dehydrated.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is false. Nephropathy is a term that refers to any disease or damage of the kidneys. Acetaminophen overdose can cause nephropathy, but it is not the most serious toxic effect. Nephropathy can manifest as reduced urine output, increased blood urea nitrogen and creatinine levels, and electrolyte imbalance.
Choice B reason: This statement is false. Tachycardia is a term that refers to a fast heart rate, usually more than 100 beats per minute. Acetaminophen overdose can cause tachycardia, but it is not the most serious toxic effect. Tachycardia can be a sign of dehydration, fever, pain, or anxiety.
Choice C reason: This statement is true. Liver dysfunction is the most serious toxic effect of acute acetaminophen overdose. Acetaminophen is metabolized by the liver and can produce a toxic byproduct that damages the liver cells. Liver dysfunction can manifest as jaundice, abdominal pain, nausea, vomiting, and elevated liver enzymes.
Choice D reason: This statement is false. Central nervous system depression is a term that refers to a reduced level of consciousness, alertness, and responsiveness. Acetaminophen overdose can cause central nervous system depression, but it is not the most serious toxic effect. Central nervous system depression can be a sign of hypoxia, hypoglycemia, or drug intoxication.
Correct Answer is C
Explanation
Choice A reason: This statement is false. 3% Sodium Chloride is a hypertonic solution that can cause fluid overload, hypernatremia, and cellular dehydration. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses.
Choice B reason: This statement is false. Dextrose 10% in water is a hypotonic solution that can cause fluid shifts, hyponatremia, and cellular edema. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses.
Choice C reason: This statement is true. 0.9% Sodium Chloride with 40 mEq Potassium (KCl) is an isotonic solution that can maintain fluid and electrolyte balance. It is indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses, especially sodium and potassium.
Choice D reason: This statement is false. Lactated Ringers is an isotonic solution that can maintain fluid and electrolyte balance, but it also contains lactate, which can be converted to bicarbonate in the liver. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who may have metabolic acidosis due to diarrhea and lactate accumulation.
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