The nurse is performing routine assessments on five hospitalized ...

[saliriagwu]

The nurse is performing routine assessments on five hospitalized clients. Which clients does the nurse expect to exhibit poor skin turgor? Select all that apply.
 
  1. The client had an open appendectomy 2 days ago.
  2. The client was admitted with severe nausea and vomiting.
  3. The client has lost 16 pounds during the last 30 days.
  4. The client has had a high fever during the last four days and was admitted through the Emergency Department last night.
  5. The client was admitted this morning with a severe migraine.

Question 2

The nurse is performing a rapid assessment for the assigned clients. Which clients require immediate medical assistance? Select all that apply.
 
  1. The client is pale and is breathing in a shallow manner.
  2. The client's oxygen saturation level is 74 and is dyspneic.
  3. The client is rating his pain at a 3 out of a 10 on a pain scale.
  4. The client is unable to follow directions.
  5. The nurse determines that the client's level of consciousness is decreasing.

[katara]

Answer to Question 1

Correct Answer: 2, 3, 4
The client who was admitted with severe nausea and vomiting will most likely exhibit signs associated with dehydration. Poor skin turgor is associated with dehydration. The client who has lost a large amount of weight will often exhibit poor skin turgor. The client who has had a high fever will often exhibit poor skin turgor due to dehydration. The client who had an open appendectomy will most likely be prepared for discharge at this time. It is unlikely that this client will exhibit poor skin turgor at this time. The client who has a severe migraine will not necessarily demonstrate signs of dehydration.

Answer to Question 2

Correct Answer: 1, 2, 4, 5
The client who is pale and breathing in a shallow manner may be exhibiting anxiety. This client should receive immediate medical attention. The client who has an oxygen saturation level of 74 and is dyspneic is exhibiting clinical manifestations associated with cardiovascular problems. This client should receive immediate medical attention. The client who is unable to follow directions should be provided with immediate medical attention. The client who has a decreasing level of consciousness during the rapid assessment should be provided with immediate medical assistance. The rapid assessment lasts less than 1 minute. This client's level of consciousness is decreasing very quickly and indicates a severe problem is occurring. The client who is complaining of only mild pain does not require immediate medical assistance.

[saliriagwu]

Gracias!

[nguyenhoanhat]

TYSM