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 D
Explanation
Choice A reason: Intracellular to the extracellular fluid shift is not the cause of low blood pressure in this case. This fluid shift occurs when the cells lose water due to osmosis, such as in dehydration or hypernatremia.
Choice B reason: Interstitial to intravascular fluid shift is not the cause of low blood pressure in this case. This fluid shift occurs when the fluid moves from the tissue spaces to the blood vessels, such as in hypovolemia or hypotonic fluid administration.
Choice C reason: Interstitial to the intracellular fluid shift is not the cause of low blood pressure in this case. This fluid shift occurs when the fluid moves from the tissue spaces to the cells, such as in overhydration or hyponatremia.
Choice D reason: Intravascular to the interstitial fluid shift is the cause of low blood pressure in this case. This fluid shift occurs when the fluid moves from the blood vessels to the tissue spaces, such as in edema, inflammation, or increased capillary permeability. This reduces the blood volume and lowers the blood pressure.
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