The client presents in the clinic with the complaint of increasing lethargy and headache. Upon physical assessment the nurse notes dry mucous membranes, sunken eyes and tenting over the sternum

Question

During the interview the client appears to be confused and is oriented to person and place. These symptoms are most likely related to? 1. Endentulism
2. Xerostomia
3. Dehydration
4. Constipation

Answer 1

3

Rationale: Endentulism is missing or loose teeth. Although this can contribute to risk factors for malnutrition, an individual can still be encouraged to increase liquid consumption as well as intake of liquid nutritional supplement. Stomatopyrosis, or burning mouth syndrome, causes an individual to complain of "taste phantoms"; that is, taste sensation that occurs in the absence of taste stimuli. Often the taste is bitter or metallic. Occurs in about 4% of U.S. Primarily affects middle age and older adults and women are seven times more likely to experience than men. Severe dehydration may a precipitating factor for constipation. Elderly individuals presenting with constipation may present with clinical symptoms of increased agitation, confusion, or incontinence. The nurse should also assess bowel sound, pain, localized masses, and distention.