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 C
Explanation
Choice A reason: This is incorrect because diffusion is the movement of solutes (dissolved substances) from an area of higher concentration to an area of lower concentration, until equilibrium is reached.
Choice B reason: This is incorrect because hydrostatic pressure is the force exerted by a fluid against a wall or a membrane. Hydrostatic pressure can drive the movement of fluid and solutes across a membrane, but it is not the movement itself.
Choice C reason: This is correct because osmosis is the movement of a pure solvent (liquid) across a semipermeable membrane from an area of lower solute concentration to an area of higher solute concentration, until equilibrium is reached.
Choice D reason: This is incorrect because ATP is not a movement, but a molecule. ATP stands for adenosine triphosphate, which is the main source of energy for cellular processes. ATP can provide energy for some types of transport across membranes, such as active transport.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.