The nurse is caring for an elderly client with a nursing diagnosis of Fluid Volume Deficit. Which of the following actions would yield the best indicator of the effectiveness of the nursing plan of care?
1. Pinch the skin on the back of the hand, and time how long it takes to return to normal.
2. Pinch the skin on the sternum, and time how long it takes to return to normal
3. Monitor the client's white blood cell count.
4. Monitor the client's intake and output.
2
Rationale: The most effective means of evaluating the client's response to treatment is to monitor skin turgor, which is best tested on the sternum or forehead, especially in elderly clients, whose loss of skin elasticity would reduce the response of skin return on the hand. White blood cell count would not change with improving fluid volume, although a deficit caused by an infection would require monitoring of WBC for resolution of the infection. Intake and output should be monitored on this client, but are not the best indicator of resolution of fluid volume deficit because they will normalize before skin turgor.
You might also like to view...
While reading a chart the nurse notes the patient has a gene mutation that affects protein structure, producing hemoglobin S. The patient will experiences symptoms of:
A) Edema B) Thrombotic organ damage C) Metastasis of a glioblastoma D) Amyotrophic lateral sclerosis
Which guideline is MOST important for the nurse to teach the client who is at risk for developing a stroke?
a. Decrease intake of caffeinated beverages. b. Reduce intake of sodium and fat. c. Monitor weight and activity. d. Monitor blood pressure level.
A patient with Raynaud's disease presents with pallor of the fingers. The patient states that the hands turn white, then blue, then red. How should the nurse explain these symptoms to the patient?
1. "Bleeding is occurring in the interior portion of your hands.". 2. "You have inflammation of the small vessels of your hands and feet that will eventually form small clots.". 3. "These symptoms are caused by spasm of the small arteries and arterioles in your hands.". 4. "Your symptoms are associated with atherosclerosis caused by too many circulating lipids.".
Which of the following would be best for a nurse to use when assessing for fremitus in a patient?
A) Dorsal hand surface B) Pads of fingers C) Palmar base (ulnar surface) D) Fist