Author Question: A 92-year-old client is brought to the emergency department with complaints of fever, nausea, and ... (Read 98 times)

MGLQZ · **on:** Jul 22, 2018

A 92-year-old client is brought to the emergency department with complaints of fever, nausea, and vomiting for the past 2 days. The client denies thirst, and urine specific gravity is below normal values.

The nurse would interpret this finding to be consistent with which of the following? 1. Fluid overload
2. Normal changes of aging
3. Dehydration
4. Congestive heart failure

Question 2

A client in the fourth stage of labor is crying out in pain. Which of the following nursing diagnoses would be the most appropriate for the client at this time?

1. Fear
2. Anxiety
3. Acute Pain
4. Health-Seeking Behaviors

morganmarie791 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3. Dehydration.

Rationale:
The elderly are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema.

Answer to Question 2

3. Acute Pain

Rationale:
In the fourth stage of labor, the diagnosis of acute pain related to perineal trauma is the most appropriate for the client at this time. The diagnoses of fear and anxiety would be appropriate during the first stage of labor. The diagnosis of health-seeking behaviors does not address the client experiencing pain during labor.