Which assessment data obtained by the home care nurse suggests that a 74-year-old client may be dehydrated?
A. The client has dry skin on the upper and lower extremities.
B. The client states that he gets up three or more times during the night to urinate.
C. The client states that he feels lightheaded when he gets out of bed or stands up.
D. The nurse observes tenting of skin on the back of the hand when testing skin tur-gor.
C
Orthostatic or postural hypotension can be caused by or worsened by dehydration.
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A young nursing student is assessing an older patient. The nurse questions whether or not to take a sexual history. What response by the faculty is best?
a. Since procreation is not an issue, you do not need to discuss this. b. Only discuss this topic if you are comfortable in doing so. c. Ask the patient if he or she wants to talk about sexuality. d. Sexuality is a basic human need and needs to be assessed.
The nurse is working on the night shift when she notices sinus bradycardia on the patient's cardiac monitor. The nurse should:
a. give atropine to increase heart rate. b. begin transcutaneous pacing of the patient. c. start a dopamine infusion to stimulate heart function. d. assess for hemodynamic instability.
A client has been diagnosed with an acquired immunodeficiency disorder and expresses concern that she might pass this disorder on to her future children. What should the nurse consider when forming a response to this concern?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Because the acquired immunodeficiency disorder is viral, it may be transmitted to the children. 2. There is a high possibility of transmitting this disease genetically. 3. This woman will likely never conceive children due to this illness. 4. Genetic transmission would occur only if genetic damage or mutation were present. 5. Genetic transmission is unlikely.
Which is most indicative of pain in an older client who is confused? (Select all that apply.)
a. Decreased blood pressure b. Screaming c. Facial grimace d. Restlessness e. Crying f. Decreased respirations