HESI Case Study Rusty Jackson question and answer.

Rusty called his son complaining that he wasn't feeling well. He had vomiting and diarrhea the past few days, and was unable to eat or drink very much, despite being thirsty. Upon arrival at Rusty's apartment, his son found him lethargic and disoriented. Data suggest that Rusty is at risk for and could be experiencing which of the following? A. fluid imbalance B. Congestive heart failure C. Urinary retention - answerA. fluid imbalance Recent episodes of vomiting and diarrhea, and the presence of dark amber urine and disorientation, suggest that Rusty is fluid deprived. He may also be experiencing electrolyte disturbances, which often accompany fluid imbalances. Besides mental status assessment, what other assessments are relevant at this time for Rusty? (Select all that apply) A. Heart rate B. Blood pressure C. Skin D. Reflexes E. Urine glucose F. Urine specific gravity G. Respirations - answerA. Heart rate B. Blood pressure C. Skin F. Urine specific gravity G. Respirations Assessment of heart rate is important. With significant fluid volume deficit, which can lead to hypovolemic shock, perfusion of tissues is decreased because less fluid is being circulated. Heart rate (pulse) quickens to increase cardiac output. An increase of 15 beats per minute is considered significant. Although Rusty's usual heart rate is not known, a heart rate of 120 is fast and indicates tachycardia. With fluid volume deficit, the palpated pulse is often weak and 'thready.' Assessment of blood pressure is important. With significant fluid volume deficit, which can lead to hypovolemic shock, perfusion of tissues is decreased because less fluid is being circulated. A compensatory vasoconstriction occurs in response to maintain arterial pressure, and