Author Question: The home health nurse cares for an alert and oriented older adult patient with a history of ... (Read 128 times)

cookcarl · **on:** Jun 25, 2018

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

a. Increase fluids if your mouth feels dry.
b. More fluids are needed if you feel thirsty.
c. Drink more fluids in the late evening hours.
d. If you feel lethargic or confused, you need more to drink.

Question 2

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

a. Blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum.

anoriega3 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.

Answer to Question 2

ANS: A
The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.