Which nursing diagnosis is appropriate for a client on a fluid restriction?

Correct Answer: B

Rationale: In the context of a client on a fluid restriction, the most appropriate nursing diagnosis is "Altered comfort: dry mouth and thirst related to restricted oral fluid" (Option B). This diagnosis addresses the specific discomfort and challenges faced by the client due to the restriction of fluid intake. Option A, "Excess fluid volume related to intake that exceeds fluid loss," is incorrect because a client on a fluid restriction is actually at risk for fluid volume deficit, not excess fluid volume. Option C, "Risk for impaired skin integrity related to compromised circulation secondary to edema," is not directly related to a fluid restriction but rather to edema and compromised circulation. Option D, "Fluid volume deficit secondary to dehydration," is close but not as specific as Option B, which directly addresses the discomfort and challenges associated with restricted oral fluid intake. In an educational context, understanding the rationale behind selecting the correct nursing diagnosis is crucial for providing effective care to clients. By choosing the appropriate diagnosis, nurses can better address the client's needs and promote optimal health outcomes. It is essential to differentiate between different nursing diagnoses to ensure accurate assessment and intervention planning based on the client's specific condition and restrictions.

Correct Answer: C

Rationale: In the context of a client in shock, the priority nursing intervention is to address acidosis, making option C the correct answer. Shock is a life-threatening condition where there is inadequate tissue perfusion leading to cellular hypoxia and anaerobic metabolism, which results in metabolic acidosis. Addressing acidosis is crucial as it can have detrimental effects on various organ systems and exacerbate the shock state. Option A, hypoxia, is a consequence of shock but is not the immediate priority because addressing acidosis will help improve tissue oxygenation. Hypercapnia (option B) and alkalosis (option D) are not typically associated with shock and are not the primary concerns in this situation. Educationally, understanding the pathophysiology of shock and its impact on the body's acid-base balance is essential for nurses to provide effective care in emergency situations. Recognizing the priority interventions in shock can help nurses prioritize care and improve patient outcomes in critical scenarios.

Correct Answer: C

Rationale: In understanding why older adults are more likely to develop hypovolemic shock, it is crucial to consider the physiological changes that occur with aging. The correct answer is C) Decreased percentage of body water. As individuals age, there is a natural decline in total body water content due to changes in body composition, decreased muscle mass, and increased adipose tissue. This decrease in body water makes older adults more susceptible to fluid loss in situations such as hemorrhage, dehydration, or severe burns, leading to hypovolemic shock. Option A) Low-activity lifestyle is incorrect because physical activity level does not directly impact the body's water content or its ability to maintain fluid balance. While regular exercise is important for overall health, it is not the primary factor contributing to hypovolemic shock in older adults. Option B) Altered cardiac function is also an important consideration in older adults, but it is not the primary reason for their increased susceptibility to hypovolemic shock. Changes in cardiac function may affect the body's ability to compensate for hypovolemia but do not directly cause the fluid loss seen in hypovolemic shock. Option D) Decline in muscle strength and bone mass is not directly related to the development of hypovolemic shock. While age-related changes in muscle and bone mass can impact overall health and mobility, they do not play a significant role in the body's ability to maintain fluid balance and prevent hypovolemic shock. Educationally, understanding the age-related changes in body composition and their implications for fluid balance is essential for healthcare providers caring for older adults. Recognizing the increased risk of hypovolemic shock in this population can guide interventions aimed at preventing and managing fluid loss to ensure optimal outcomes for older patients.

Correct Answer: A

Rationale: In the field of pharmacology, understanding the basic principles of assessing sensory functions like hearing acuity is crucial for providing comprehensive patient care. In this context, the correct answer to the question regarding the dB level at which a client with normal hearing first perceives sound is A) 4 dB. The rationale behind this is rooted in audiometric testing standards, where the threshold for normal hearing is typically set at 0-25 dB for adults. A sound intensity level of 0-25 dB is considered to be within the range of normal human hearing perception. Therefore, when a client reports first perceiving sound at 4 dB, it indicates that their hearing ability falls within the normal range. Analyzing the incorrect options: B) 8 dB, C) 12 dB, and D) 16 dB are higher dB levels compared to the generally accepted range for normal hearing perception. Individuals with normal hearing usually detect sound at lower decibel levels, closer to the threshold of 0 dB. Selecting any of these options would imply an elevated hearing threshold, which is not indicative of normal hearing acuity. Educational context: This question serves to reinforce the importance of understanding audiometric principles in the context of pharmacological practice. Pharmacists and healthcare professionals need to be aware of basic audiometric parameters to assess and address potential medication side effects related to hearing loss or ototoxicity. By grasping these fundamental concepts, healthcare providers can better monitor and manage the aural health of their patients.

Correct Answer: B

Rationale: In pharmacology, understanding the importance of preventive care is crucial. The correct answer to the question is option B) Initially, a thorough exam at the age of 40. This is because individuals without a family history of eye disease should have a baseline eye exam at the age of 40 to detect any early signs of eye conditions such as glaucoma or macular degeneration. Option A) Annually after the age of 30 is incorrect because starting annual eye exams at age 30 is not necessary for individuals without a family history of eye disease. Option C) Initially, a thorough exam at the age of 50 is too late as many eye conditions can develop before the age of 50. Option D) Annually after the age of 50 is also incorrect as waiting until age 50 for the first eye exam may miss early signs of eye diseases that are more effectively treated when detected early. Educationally, it is important for healthcare providers to understand the recommended guidelines for eye exams based on age and risk factors to provide appropriate care to their patients. This question highlights the significance of early detection and regular eye exams in maintaining optimal eye health, especially in individuals without a family history of eye disease who may not be as vigilant about seeking eye care.