, The RN is assessing a 70-year-old client admitted to the unit with severe
dehydration. Which finding requires immediate intervention by the nurse?
A. Client behavior that changes from anxious to lethargic
B. Deep furrows on the surface of the tongue
C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched
D. Urine output of 950 mL for the past 24 hours - CORRECT ANSWERS -A. Client
behavior that changes from anxious to lethargic
RATIONALE:
Immediate intervention by the nurse is required when a client's behavior changes from
anxious to lethargic. This change in mental status suggests poor cerebral blood flow
and fluid shifts within the brain cells. Immediate intervention is needed to prevent further
cerebral dysfunction.Deep furrows on the surface of the tongue, poor skin turgor, and
low urine output are all caused by the fluid volume deficit, but do not indicate
complications of dehydration that are immediately life-threatening.
A client with diarrhea for 3 days and inability to eat or drink well is brought to the
emergency department (ED) by her family. She states she has been taking her diuretics
for congestive heart failure (CHF). What nursing actions are indicated at this time?
SELECT ALL THAT APPLY.
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
C. Administer the ordered diuretic.
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring. - CORRECT ANSWERS -A, B, D, E
RATIONALE:
Nursing actions indicated at this time include: placing the client on bedrest and assisting
the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension,
and applying a cardiac monitor. Safety is required to prevent falls due to weakness from
a likely fluid volume deficit and electrolyte imbalance. The nurse should review the
laboratory and diagnostic results to detect likely loss of sodium, potassium, and
magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely with
diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially
hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit.
Monitoring for inverted T wave or presence of U wave on the ECG as well as
dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of
dehydration. Which finding requires immediate intervention by the nurse?
A. Client behavior that changes from anxious to lethargic
B. Deep furrows on the surface of the tongue
C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched
D. Urine output of 950 mL for the past 24 hours - CORRECT ANSWERS -A. Client
behavior that changes from anxious to lethargic
RATIONALE:
Immediate intervention by the nurse is required when a client's behavior changes from
anxious to lethargic. This change in mental status suggests poor cerebral blood flow
and fluid shifts within the brain cells. Immediate intervention is needed to prevent further
cerebral dysfunction.Deep furrows on the surface of the tongue, poor skin turgor, and
low urine output are all caused by the fluid volume deficit, but do not indicate
complications of dehydration that are immediately life-threatening.
A client with diarrhea for 3 days and inability to eat or drink well is brought to the
emergency department (ED) by her family. She states she has been taking her diuretics
for congestive heart failure (CHF). What nursing actions are indicated at this time?
SELECT ALL THAT APPLY.
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
C. Administer the ordered diuretic.
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring. - CORRECT ANSWERS -A, B, D, E
RATIONALE:
Nursing actions indicated at this time include: placing the client on bedrest and assisting
the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension,
and applying a cardiac monitor. Safety is required to prevent falls due to weakness from
a likely fluid volume deficit and electrolyte imbalance. The nurse should review the
laboratory and diagnostic results to detect likely loss of sodium, potassium, and
magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely with
diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially
hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit.
Monitoring for inverted T wave or presence of U wave on the ECG as well as
dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of
