how does a nurse assess for dehydration in an elderly patient

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form B

1. How can dehydration be assessed in an elderly patient?

A. Checking skin turgor on the forearm
B. Assessing for dry mucous membranes
C. Checking for orthostatic hypotension
D. Measuring daily weights

Correct answer: A

Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.

2. A hospice nurse is providing teaching to a client who has a new diagnosis of a terminal illness and her family. Which of the following statements should the nurse include in the teaching?

A. Hospice care focuses on providing comfort and symptom management.
B. The provider will coordinate your health care needs while in hospice.
C. You do not need to choose a family caregiver before being admitted into a hospice facility.
D. Hospice care continues to help families with grief after a death occurs.

Correct answer: D

Rationale: The correct answer is D because hospice care provides ongoing support to families with grief even after a patient's death. Choice A is incorrect because hospice care focuses on providing comfort and symptom management rather than disease treatment and rehabilitation. Choice B is incorrect as the statement does not accurately reflect the role of a hospice provider. Choice C is incorrect; a family caregiver is not a prerequisite for admission into a hospice facility.

3. Which factor places a patient at the highest risk for infection?

A. A healthy immune system
B. Presence of chronic illness
C. Being well-nourished
D. Age over 65 years

Correct answer: B

Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.

4. A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

A. Suggest that the client use a salt substitute
B. Obtain a 12-lead ECG
C. Obtain a blood sample for a serum sodium level
D. Advise the client to add citrus juices and bananas to their diet

Correct answer: B

Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.

5. What are the instructions for a behind-the-ear hearing aid?

A. Remove before sleeping
B. Remove before shower
C. Keep on during all activities
D. Replace every week

Correct answer: B

Rationale: The correct answer is to remove a behind-the-ear hearing aid before showering to prevent water damage. Choice A is incorrect because it is safe to wear the hearing aid while sleeping as it does not pose a risk of damage. Choice C is incorrect because it is advisable to remove the hearing aid during certain activities to prevent damage or loss. Choice D is incorrect as hearing aids do not need to be replaced weekly unless there is an issue with the device.