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: Panting with mouth open is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the risk of hyperventilation and respiratory alkalosis, which could worsen the anxiety and cause symptoms such as dizziness, tingling, and muscle spasms.
Choice B reason: Sitting up is an appropriate intervention for an anxious patient with a high respiratory rate. This could help the patient relax and breathe more deeply and slowly, which could reduce the anxiety and normalize the blood gas levels.
Choice C reason: Lying down is not an appropriate intervention for an anxious patient with a high respiratory rate. This could make the patient feel more claustrophobic and increase the anxiety and the respiratory rate.
Choice D reason: Breathing through a re-breather mask is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the oxygen concentration in the blood, which could reduce the stimulus for breathing and cause respiratory depression.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because the adrenal gland is not involved in the thirst mechanism. The adrenal gland is responsible for producing hormones such as cortisol, aldosterone, and adrenaline, which regulate stress response, blood pressure, and metabolism.
Choice B reason: This is incorrect because the cerebral cortex is not involved in the thirst mechanism. The cerebral cortex is the outer layer of the brain that is responsible for higher cognitive functions such as memory, language, and reasoning.
Choice C reason: This is incorrect because the pituitary gland is not directly involved in the thirst mechanism. The pituitary gland is a small gland at the base of the brain that produces hormones that control growth, reproduction, and metabolism. However, the pituitary gland does secrete antidiuretic hormone (ADH), which is regulated by the hypothalamus and affects water balance in the body.
Choice D reason: This is correct because the hypothalamus is the location of the thirst mechanism. The hypothalamus is a part of the brain that regulates many bodily functions such as temperature, appetite, sleep, and emotions. The hypothalamus also monitors the blood osmolarity and triggers the sensation of thirst when the blood is too concentrated.
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