The older client who was NPO for eight hours before a diagnostic procedure returns from the test. Which client data is the nurse's priority assessment?
1. Dehydration
2. Disorientation
3. Skin breakdown
4. Mucosal irritation
1
1. Older adult clients are especially prone to dehydration, and the risk increases after a prolonged NPO period because the nurse withholds food and fluid to prepare the older client for the procedure. Emptying the stomach decreases the risk of aspiration of gastric contents during and after the procedure.
2. Disorientation is a reasonable assessment for an older adult who has received in-adequate fluid and risks dehydration; it may be a clinical indicator of dehydration.
3. The risk of skin breakdown is increased with dehydration. It is not as important as early detection of dehydration because preventing dehydration helps to prevent skin breakdown.
4. Mucosal irritation is a sign of dehydration.
You might also like to view...
To develop an accurate hospital staffing pattern, patients must be classified according to ____
a. Age and gender b. Functional level c. Number of illnesses d. Severity of illness
A home health nurse is making a home visit to an older patient. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. Which of the following are hazards in the home? (Select all that apply.)
a. The absence of railings on the stairway b. Night-lights in all rooms c. Clutter throughout the home d. A small throw rug outside of the shower stall e. Grab bars in bathroom beside toilet
The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation, how should the extremity feel?
1. Cool, with a capillary refill of greater than 3 seconds 2. With a palpable dorsalis pedis pulse but an absent posterior tibial pulse 3. Decreased sensation, with an absent dorsalis pedis pulse 4. Warm, with a capillary refill less than 3 seconds
The parents of a 6-year-old have just been told that their child will die shortly. At which age does the nurse realize that children are capable of understanding death?
A) 3 years B) 6 years C) 9 years D) 12 years