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

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

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 patients 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:

2. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?

A. Agitation
B. Kussmaul respirations
C. Seizures
D. Positive Chvosteks sign

Correct answer: B

Rationale:

3. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)

A. Electrocardiogram changes
B. Slow, shallow respirations
C. Paralytic ileus
D. Skeletal muscle weakness

Correct answer: B

Rationale:

4. What is the main water-holding force in the blood capillaries?

A. Capillary blood pressure
B. Sodium in the blood plasma
C. Protein in the blood plasma
D. Chloride in the blood plasma

Correct answer: C

Rationale: The correct answer is C: Protein in the blood plasma. Plasma proteins, especially albumin, create oncotic pressure, which is the main force responsible for holding water within the blood capillaries. Capillary blood pressure (Choice A) is involved in pushing blood through the capillaries, while sodium and chloride in the blood plasma (Choices B and D) are electrolytes and do not play a significant role in the water-holding force within capillaries.

5. Which of the following is not considered an extracellular fluid?

A. Cerebrospinal fluid
B. The humors of the eye
C. Lymph
D. Cerebrospinal fluid and the humors of the eye

Correct answer: D

Rationale: The correct answer is D. Cerebrospinal fluid and the humors of the eye are not considered extracellular fluids. Extracellular fluids are fluids found outside the cells, such as interstitial fluid and lymph. Cerebrospinal fluid is found within the central nervous system, while the humors of the eye (aqueous humor and vitreous humor) are located within the eyeball, making them distinct from extracellular fluids.