you are performing an admission assessment on an older adult patient newly admitted for end stage liver disease what principle should guide your asses

ATI RN

ATI Fluid and Electrolytes

1. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor?

A. Overhydration is common among healthy older adults.
B. Dehydration causes the skin to appear spongy.
C. Inelastic skin turgor is a normal part of aging.
D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Choice A is incorrect because overhydration is not common among healthy older adults. Choice B is incorrect because dehydration leads to inelastic skin, not sponginess. Choice D is incorrect as skin turgor assessment can be done in patients of any age, including those over 70.

2. A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?

A. Hydrostatic pressure
B. Osmosis and osmolality
C. Diffusion
D. Active transport

Correct answer: B

Rationale: The correct answer is B: Osmosis and osmolality. Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. In this case, the hypertonic solution increases the number of dissolved particles in the blood, causing fluids to shift into the capillaries due to the osmotic pressure gradient. Osmolality refers to the concentration of solutes in a solution. Hydrostatic pressure refers to changes in water or volume related to water pressure, not the movement of fluids due to solute concentration differences. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; in an intact vascular system, solutes are unable to move freely, so diffusion does not play a significant role in this scenario. Active transport involves the movement of molecules against the concentration gradient with the use of energy, typically at the cellular level, and is not related to the vascular volume changes described in the question.

3. What is the main force that pushes fluid in blood capillaries?

A. Blood pressure.
B. Sodium in the blood plasma.
C. Sodium in the interstitial fluid.
D. Protein in the blood plasma.

Correct answer: A

Rationale: The correct answer is A, blood pressure. Blood pressure is the primary force that pushes fluid out of the capillaries into the surrounding tissues. This pressure difference is essential for the exchange of nutrients, gases, and waste products between the blood and tissues. Choices B, C, and D are incorrect as they do not represent the primary force responsible for pushing fluid in blood capillaries.

4. What happens first in dehydration?

A. Intercellular fluid volume drops first.
B. Plasma volume drops first.
C. Interstitial fluid drops first.
D. Neither interstitial nor intracellular fluid volume are affected.

Correct answer: C

Rationale: In dehydration, the body first draws fluid from the interstitial space to maintain blood volume, leading to a decrease in interstitial fluid volume. This is why choice C is correct. Choice A is incorrect because intracellular fluid is not the first to be affected. Choice B is also incorrect as plasma volume reduction typically occurs after interstitial fluid loss. Choice D is incorrect as dehydration impacts both interstitial and intracellular fluid volumes.

5. A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment, the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:

A. Hypophosphatemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hyperkalemia

Correct answer: B

Rationale: The patient's symptoms of tingling in the lips and fingers along with the wrist and hand spasm are indicative of tetany, a characteristic manifestation of hypocalcemia. Hypocalcemia and hypomagnesemia can present with sensations of tingling in the extremities and around the mouth. The spasm in the wrist and hand when taking blood pressure could be due to slight ischemia of the ulnar nerve, further supporting the suspicion of hypocalcemia in this patient. Hypophosphatemia, hypermagnesemia, and hyperkalemia do not typically present with these specific symptoms and manifestations.