The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery
The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response?
A) "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup."
B) "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids."
C) "It is normal to be a little confused following surgery, and it is safe not to urinate at night."
D) "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. "
Ans: B
Feedback:
In elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.
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