a nurse is caring for an older adult client who is admitted with moderate dehydration which intervention should the nurse implement to prevent injury a nurse is caring for an older adult client who is admitted with moderate dehydration which intervention should the nurse implement to prevent injury
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ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

Correct answer: Dangle the client on the bedside before ambulating.

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.

2. Which of the following is a self-conscious emotion?

Correct answer: A

Rationale: The correct answer is A, guilt. Guilt is a self-conscious emotion that involves reflecting on one's actions and feeling remorse. Self-conscious emotions are those that require self-reflection and self-evaluation. Choices B, C, and D are not self-conscious emotions. Happiness and fear are not self-conscious emotions as they do not necessarily involve self-reflection. Interest is not a self-conscious emotion but rather a feeling of curiosity or attraction towards something.

3. According to psychosexual theory, what is crucial for healthy personality development?

Correct answer: C

Rationale: According to psychosexual theory, developed by Sigmund Freud, how parents manage their child's sexual and aggressive drives in the first few years is crucial for healthy personality development. This theory suggests that personality development is heavily influenced by a child's experiences during early stages of development, particularly related to handling sexual and aggressive impulses. Choices A, B, and D are incorrect as they do not align with the core principles of psychosexual theory, which focuses on the importance of early childhood experiences, especially in the context of sexual and aggressive drives.

4. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

Correct answer: C

Rationale: The correct answer is C. Taking aspirin is not recommended during periods of bone marrow suppression as it can increase the risk of bleeding. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can impair platelet function, further exacerbating the risk of bleeding. Choices A, B, and D are all appropriate statements for a client at risk for bleeding and undergoing chemotherapy. Blowing the nose gently, being prepared for a platelet transfusion if needed, and monitoring menstrual bleeding are all important aspects of self-care during this period.

5. Which action is an example of secondary prevention in public health?

Correct answer: C

Rationale: The correct answer is screening for early signs of disease (Choice C). Secondary prevention focuses on early detection and treatment of diseases to prevent their progression. By screening for early signs of disease, individuals can receive timely interventions, leading to better health outcomes. Administering vaccines (Choice A) falls under primary prevention by preventing the occurrence of diseases. Providing treatment for chronic diseases (Choice B) is part of tertiary prevention, which focuses on managing and reducing complications of established diseases. Offering health education workshops (Choice D) can be part of primary prevention by promoting healthy behaviors to prevent diseases.

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