The nurse caring for a frail 92-year-old dehydrated patient should add to the plan of care:
Potential for over-hydration related to excessive thirst
Potential for diarrhea related to dehydration
Potential for pulmonary congestion related to excessive fluid intake
Potential for fall related to confusion
The Correct Answer is D
Choice A reason: This is incorrect because over-hydration is unlikely in a dehydrated patient. Over-hydration is a condition where the body has too much water, which can cause hyponatremia, edema, and cerebral swelling.
Choice B reason: This is incorrect because diarrhea is a cause, not a consequence, of dehydration. Diarrhea is the frequent and watery passage of stool, which can lead to fluid and electrolyte loss.
Choice C reason: This is incorrect because pulmonary congestion is also unlikely in a dehydrated patient. Pulmonary congestion is a condition where the lungs are filled with fluid, which can cause dyspnea, cough, and crackles.
Choice D reason: This is correct because fall is a potential complication of dehydration. Dehydration can cause confusion, dizziness, weakness, and hypotension, which can increase the risk of falling and injuring oneself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Sodium (Na+) imbalance can cause neurological symptoms such as confusion, seizures, or coma, but not abdominal pain or urinary retention.
Choice B reason: Calcium (Ca2+) imbalance can cause abdominal pain, urinary retention, and confusion, as well as muscle weakness, bone pain, and cardiac arrhythmias. These signs are the result of an inadequate supply of calcium, which is essential for nerve and muscle function, as well as bone health.
Choice C reason: Chloride (Cl-) imbalance can cause acid-base disorders such as metabolic acidosis or alkalosis, but not abdominal pain, urinary retention, or confusion.
Choice D reason: Phosphates (PO4^3^-) imbalance can cause bone and muscle problems, such as rickets, osteomalacia, or tetany, but not abdominal pain, urinary retention, or confusion.
Choice E reason: Potassium (K+) imbalance can cause cardiac and neuromuscular symptoms, such as arrhythmias, palpitations, muscle weakness, or paralysis, but not abdominal pain, urinary retention, or confusion.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because this represents respiratory alkalosis, not acidosis. Respiratory alkalosis is characterized by a high pH and a low PCO2.
Choice B reason: This is incorrect because this represents a mixed disorder, not a pure respiratory acidosis. A mixed disorder occurs when both the pH and the PCO2 are abnormal, but in opposite directions.
Choice C reason: This is correct because this represents respiratory acidosis. Respiratory acidosis is characterized by a low pH and a high PCO2.
Choice D reason: This is incorrect because this represents normal values, not respiratory acidosis. Normal values for pH and PCO2 are 7.35 to 7.45 and 35 to 45 mmHg, respectively.
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