A 64-year-old client and spouse are in the clinic because of the ...

[bobbysung]

A 64-year-old client and spouse are in the clinic because of the client's fever, chills, nausea, and vomiting. The nurse conducts a physical assessment and notes that the client's skin is dry with slight tenting. The nurse prepares to:
 
  1. Assess for dehydration.
   2. Administer fluids.
   3. Check for pedal edema.
   4. Ask the spouse for more information.

Question 2

A patient tells the nurse that he uses an active form of physical stimulation to decrease his pain. Which of the following is an active form of physical stimulation?
 
  a. Tai chi c. shiatsu
  b. Swedish massage d. myofacial release

[cegalasso]

Answer to Question 1

1. Assess further for dehydration.

Rationale:
Dry skin with slight tenting is a normal finding in the older client. The nurse would assess for other signs and symptoms of dehydration and not rely on dry skin and tenting as a sign. Until the nurse has made further assessments and without a physician's orders, the nurse should not administer fluids. The client exhibits symptoms of an infection, not of edema or heart failure. The nurse does not assume that the client cannot answer health history questions.

Answer to Question 2

A
Active forms of physical stimulation include Tai Chi and yoga. Passive forms of physical stimulation include massage.

[bobbysung]

Excellent

[ryhom]

TYSM