Author Question: The nurse notices that an older adult's urine is greenish-brown. Which step should the nurse ... (Read 78 times)

09madisonrousseau09 · **on:** Jul 11, 2018

The nurse notices that an older adult's urine is greenish-brown. Which step should the nurse implement next?

a. Increase oral fluid intake. c. Evaluate the medi-cation list.
b. Review laboratory reports. d. Determine fluid volume status.

Question 2

An older male adult who had radical surgery for oral cancer is refusing to see visitors and is losing weight despite aggressive nutrition therapy. The nurse assesses this man for in-effective coping related to dysfunctional grieving.

Which is the most important patient outcome of nursing care implemented in response to his mental health status? a. Discusses how his coping mechanisms are overwhelmed
b. Performs self-feedings through gastrostomy tube daily
c. Uses nonverbal forms of communication effectively
d. Exhibits self-confidence in regaining sense of control

kescobar@64 · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

D
The nurse assesses the older adult's fluid status to develop a suitable plan of care. The nurse se-lects the correct nursing interventions, depending on the cause of the problem. Increasing oral fluid intake is implemented after the nurse completes the fluid assessment, if the intervention is determined to be suitable. The nurse reviews pertinent laboratory data as part of the fluid as-sessment. The nurse evaluates the medication list as part of the fluid assessment to eliminate a medication as the cause of the dark urine.

Answer to Question 2

D

Feedback
A Incorrect. The patient displays lack of readiness for expressions about emotions, coping, or his stressors; by enhancing his self-confidence, the nurse prepares him to discuss coping mechanisms and stressors.
B Incorrect. This patient displays a lack of readiness for learning a new psycho-motor activity. This outcome gains importance as the day for discharge ap-proaches.
C Incorrect. This outcome is important for basic communication; however, he dis-plays a lack of readiness for receiving help to achieve this outcome.
D Correct. The most important element of the nursing plan of care for this older adult is to create and strengthen self-confidence to improve his sense of control because doing so is likely to help him manage other aspects of this health care effectively. The nurse helps to create and improve this self-confidence by ob-serving for strengths and integrating them into daily care and by responding with empathy and encouragement to expressions of fears, emotions, and desira-ble goals. This is the most important outcome because this man has clinical in-dicators for depression: social isolation and weight loss. Before he can benefit from discussing his stressors or from patient teaching, the nurse must establish a trusting, caring relationship and build some self-confidence because, at this point, this individual feels hopeless and that he has no control.