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. 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.

3. Which hormone reduces the amount of water in the body?

A. ADH
B. aldosterone
C. ANH
D. ADH and aldosterone

Correct answer: B

Rationale: The correct answer is 'aldosterone.' Aldosterone is the hormone that reduces the amount of water in the body by increasing the reabsorption of sodium and water from the kidney tubules. ANH (atrial natriuretic hormone) actually works to increase the excretion of sodium and water by the kidneys, leading to a reduction in blood volume and pressure. ADH (antidiuretic hormone) works to increase water reabsorption by the kidneys, thereby increasing blood volume. Therefore, choices A (ADH) and D (ADH and aldosterone) are incorrect in the context of reducing the amount of water in the body.

4. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

A. I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup
B. Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.
C. It is normal to be a little confused following surgery, and it is safe not to urinate at night.
D. If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

Correct answer: B

Rationale:

5. Which of the following organs does not contribute to fluid output from the body?

A. Lungs
B. Skin
C. Intestine
D. Lungs, skin, and intestine

Correct answer: D

Rationale: The correct answer is D. All the listed organs (lungs, skin, and intestines) contribute to fluid loss from the body. Lungs contribute to fluid loss through respiration, skin through sweating, and intestines through excretion. Therefore, none of the organs listed in the options retain fluids within the body. Choices A, B, and C are incorrect because all of these organs play a role in fluid output from the body.