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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect because bradypnea is a term for slow breathing, usually less than 12 breaths per minute. The client is breathing rapidly, not slowly.
Choice B reason: This is correct because Kussmaul's respirations are a type of breathing pattern that is deep, regular, and rapid, usually more than 20 breaths per minute. Kussmaul's respirations are a sign of metabolic acidosis, which occurs in diabetic ketoacidosis due to the accumulation of ketones in the blood. The client is trying to exhale the excess carbon dioxide and lower the acidity of the blood.
Choice C reason: This is incorrect because Cheyne-Stokes respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) alternating with periods of rapid breathing. Cheyne-Stokes respirations are a sign of cerebral dysfunction, such as stroke, brain injury, or coma.
Choice D reason: This is incorrect because Biot's respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) interspersed with periods of normal breathing. Biot's respirations are a sign of brainstem damage, such as meningitis, encephalitis, or head trauma.
Correct Answer is D
Explanation
Choice A reason: This is correct because prolonged bed rest can cause hypocalcemia, or low serum calcium level. Calcium is stored in the bones and is released into the blood when the bones are stressed by weight-bearing activities. When a person is on bed rest, the bones are not stimulated and the calcium remains in the bones, leading to a decrease in serum calcium level.
Choice B reason: This is incorrect because too much butter consumption does not affect the serum calcium level directly. Butter is a source of fat and calories, which can affect the cholesterol and triglyceride levels, but not the calcium level. However, too much butter consumption can cause obesity, which can increase the risk of osteoporosis and fractures.
Choice C reason: This is incorrect because hyperparathyroidism can cause hypercalcemia, or high serum calcium level. Hyperparathyroidism is a condition where the parathyroid glands produce too much parathyroid hormone (PTH), which regulates the calcium and phosphorus balance in the body. PTH stimulates the release of calcium from the bones into the blood, leading to an increase in serum calcium level.
Choice D reason: This is incorrect because excessive ingestion of vitamin D can also cause hypercalcemia, or high serum calcium level. Vitamin D is a fat-soluble vitamin that helps the body absorb calcium from the food and supplements. When a person takes too much vitamin D, the calcium absorption is increased and the serum calcium level rises.
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