a 73 year old man who slipped on a small carpet in his home and fell on his hip is alert and oriented perrla pupils equally round and reactive to ligh

ATI RN

Fluid and Electrolytes ATI

1. A 73-year-old man who slipped on a small carpet in his home and fell on his hip is alert and oriented; PERRLA (pupils equally round and reactive to light and accommodation) is intact, and he has come by ambulance to the emergency department (ED). Heart rate elevated, he is anxious and thirsty. A Foley catheter is in place and 40mL of urine is present. The nurse's most likely explanation for the urine output is:

A. The man urinated prior to his arrival in the ED and will probably not need to have the Foley catheter kept in place.
B. The man has a brain injury, lacks ADH, and needs vasopressin.
C. The man is in heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output.
D. He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

Correct answer: D

Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output. Choices A, B, and C are incorrect because there is no indication of urination prior to arrival, brain injury, lack of ADH, or heart failure present in the scenario provided. The symptoms and context described point more towards a physiological response related to the sympathetic nervous system and the renin-angiotensin-aldosterone system rather than the other conditions mentioned.

2. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?

A. Diarrhea and vomiting for 36 hours
B. . Anxiety-induced hyperventilation
C. Chronic obstructive pulmonary disease (COPD)
D. Diabetic ketoacidosis and emphysema

Correct answer: B

Rationale:

3. What fluid is found in spaces between the cells?

A. Intracellular fluid
B. Interstitial fluid
C. Plasma
D. Electrolyte

Correct answer: B

Rationale: The correct answer is B, Interstitial fluid. Interstitial fluid is the fluid that surrounds and occupies the spaces between cells, providing them with nutrients and removing waste. Choices A, C, and D are incorrect because intracellular fluid refers to fluid inside cells, plasma refers to the liquid component of blood, and electrolyte refers to substances that dissociate into ions in solution, affecting fluid balance but not specifically found in spaces between cells.

4. The nurse assessing skin turgor in an elderly patient should remember that:

A. Overhydration causes the skin to tent.
B. Dehydration causes the skin to appear edematous and spongy.
C. Inelastic skin turgor is a normal part of aging.
D. Normal skin turgor is moist and boggy.

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.