A nurse assesses a client who is admitted for treatment of fluid ...

[s.tung]

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)
 
  a. Increased pulse rate
  b. Distended neck veins
  c. Decreased blood pressure
  d. Warm and pink skin
  e. Skeletal muscle weakness

Question 2

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
 
  a. Ask family members to speak quietly to keep the client calm.
  b. Assess urine color, amount, and specific gravity each day.
  c. Encourage the client to drink at least 1 liter of fluids each shift.
  d. Dangle the client on the bedside before ambulating.

[pikon]

Answer to Question 1

ANS: A, B, E
Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.

Answer to Question 2

ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

[s.tung]

Correct answers!

[pikon]

Great! Please up vote