The nurse is caring for an older adult client who has an infection and a fever of 38°C (100.4°F).
The nurse should monitor the client for which of the following complications?
Dehydration
Hypothermia
Seizures
Delirium
The Correct Answer is D
The correct answer is D.
Delirium.
The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.
Delirium can affect the client’s cognition, attention, orientation, memory, and behavior. It can also increase the risk of falls, complications, and mortality.
Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.
Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature. Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.
Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.
Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure. Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.
Choice C is wrong because seizures are not a common complication of fever in older adults.
Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.
Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.
Fever-induced seizures are more likely to occur in young children than in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Dehydration.
Poor skin turgor means that the skin takes longer to return to its normal position after being pinched or pulled.
This is a sign of dehydration, which means the body does not have enough fluid.
Dehydration can be caused by not drinking enough water, vomiting, diarrhea, fever, diabetes, or other conditions that affect fluid balance.
Choice B is wrong because malnutrition does not directly affect skin turgor.
Malnutrition means the body does not get enough nutrients from food.
This can cause various problems, such as weight loss, muscle wasting, poor wound healing, and infections.
However, malnutrition does not cause the skin to lose its elasticity.
Choice C is wrong because loss of subcutaneous fat does not cause poor skin turgor.
Subcutaneous fat is the layer of fat under the skin that helps insulate the body and store energy.
As people age, they tend to lose some subcutaneous fat, especially in the face and hands.
This can make the skin look thinner and more wrinkled, but it does not affect how quickly the skin snaps back after being pinched.
Choice D is wrong because reduced collagen fibers do not cause poor skin turgor.
Collagen is a protein that gives the skin its strength and structure.
As people age, they produce less collagen, which can make the skin sag and lose firmness.
However, collagen does not affect the skin’s ability to retain water and return to its normal shape after being stretched.
Normal ranges for skin turgor vary depending on the age and location of the skin.
In general, healthy skin should return to its normal position within 2 seconds after being pinched.
In children and young adults, skin turgor can be tested on the abdomen or forearm.In elderly people, skin turgor can be tested on the clavicle (collar bone), sternum (breastbone), forehead, or inner thigh.These sites are less affected by skin wrinkling and aging.
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer isA, B, C and E.These interventions are consistent with the best practices for optimizing functional status in the elderly.
Some explanations for the choices are:.
• Choice A is correct because physical activity and exercise can help maintain muscle strength, joint mobility, balance and coordination, which are essential for functional independence and quality of life.
• Choice B is correct because adequate nutrition and hydration can prevent malnutrition, dehydration and electrolyte imbalance, which can impair physical and cognitive function and increase the risk of complications.
• Choice C is correct because managing chronic diseases and medications can prevent complications, adverse effects and polypharmacy, which can affect functional status and increase the need for health care services.
• Choice D is wrong because providing assistive devices and adaptive equipment is not an intervention to improve functional status, but rather to enhance mobility, safety and independence for patients who already have functional limitations.
The question asks for interventions to improve functional status, not to compensate for it.
• Choice E is correct because modifying the environment can reduce hazards, improve accessibility and facilitate self-care, which can promote functional independence and prevent injuries or falls.
The normal ranges for blood glucose and blood pressure for older adults with diabetes and hypertension are:.
• Blood glucose: 80-130 mg/dL before meals and less than 180 mg/dL after meals.
• Blood pressure: less than 140/90 mmHg or individualized based on comorbidities and risk factors.
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