Question 1

A client with an elevated body temperature and excessive sweating is prescribed intake and output measurements. What should the nurse include when making these measurements? (Select all that apply.)

Accepted Answer

Water lost from the body by sweating is referred to as insensible water loss because it is difficult to measure. Sensible water loss refers to water loss which is measurable such as water eliminated in urine. Both types of water lost are calculated to monitor for dehydration. Indeterminate, uncompensated, and indiscriminate are not terms used to define water loss.
Water lost from the body by sweating is referred to as insensible water loss because it is difficult to measure. Sensible water loss refers to water loss which is measurable such as water eliminated in urine. Both types of water lost are calculated to monitor for dehydration. Indeterminate, uncompensated, and indiscriminate are not terms used to define water loss.

Question 2

The nurse is concerned about a critically ill client's fluid intake because intravenous fluids have expired. For which role of water in the human body should the nurse be most concerned in this client?

Accepted Answer

Water has many important roles in the human body including transportation of nutrients and other substances; regulation of the core body temperature; removal of waste products; and lubricant for joints, eyes, and mucous membranes. Water is lost during fecal elimination, but does not cause the process. Weight is affected by the amount of water in the body, but is not stabilized by it. Euhydration refers to a state of water balance.

Question 3

The nurse prepares to care for a group of assigned clients. Which body substance should the nurse recall that helps maintain an even core body temperature?

Accepted Answer

Heat produced by metabolism and physical activity are absorbed by water in the body and dissipated to maintain an even core body temperature. This type of water loss is referred to as insensible since it is difficult to measure.

Question 4

A client with Alzheimer disease in an assisted living complex has been treated for dehydration because of not drinking fluid unless it is offered. Which approach should the nurse use to monitor this client's hydration status?

Accepted Answer

Clients with Alzheimer disease often have a blunted response to thirst and need to be monitored closely to avoid dehydration. Keeping a record of the daily intake and output will provide a tool for determining fluid needs. Coffee has been linked with water loss and may exacerbate the situation. Dependency on others for fluids is always a risk for dehydration, and frequent reminders and coaching is needed even if fluids are in the proximity.

Question 5

A critically ill younger client has an elevated serum sodium level. Which action should the nurse take after learning of this laboratory value?

Accepted Answer

Assessing a client for skin turgor or "tenting"
can be used to screen for hydration status. Although this may not be useful in older adults due to subcutaneous tissue loss and changes in skin elasticity related to aging, it may be a good indicator in a younger client. Hypernatremia refers to elevated serum sodium levels and signals the loss of water from the extracellular fluid. The condition of hypernatremia does not impact the client's oxygenation status, temperature or result in edema.

Question 6

A client who experiences fatigue, elevated temperature, and confusion after running a marathon has a urine specific gravity of 1.039. What should the nurse suspect be occurring with this client?

Accepted Answer

Normal specific gravity values are 1.002-1.028. A urine specific gravity of 1.030 or greater is a sign of dehydration. This diagnosis is supported by complaints of confusion, fatigue, and elevated temperature. Overhydration and water toxicity are terms used to describe an excessive intake of water, a condition usually found in clients with schizophrenia and other mental illnesses. Euhydration is a state of balanced body fluids.

Question 7

The nurse assesses an older client with altered cognition. Which finding indicates to the nurse the client has an alteration in fluid balance? (Select all that apply.)

Accepted Answer

Older clients with altered cognition are at risk for dehydration. When performing a physical assessment there are several signs that may indicate that the client has an altered fluid status including: dry oral mucosa, dark colored urine, and increased heart rate. Lower extremity edema is linked to excess fluid volume and increased respiratory rate is not affected by hydration status.
Older clients with altered cognition are at risk for dehydration. When performing a physical assessment there are several signs that may indicate that the client has an altered fluid status including: dry oral mucosa, dark colored urine, and increased heart rate. Lower extremity edema is linked to excess fluid volume and increased respiratory rate is not affected by hydration status.
Older clients with altered cognition are at risk for dehydration. When performing a physical assessment there are several signs that may indicate that the client has an altered fluid status including: dry oral mucosa, dark colored urine, and increased heart rate. Lower extremity edema is linked to excess fluid volume and increased respiratory rate is not affected by hydration status.

Question 8

A client is experiencing confusion, rapid heart rate, and an elevated body temperature. For which health problem should the nurse plan care for this client?

Accepted Answer

The combination of symptoms indicates an alteration in fluid status. There is not enough information to determine if a virus is causing the client's symptoms. Fever and increased heart rate are symptoms of an altered fluid status.

Question 9

An older client is experiencing dizziness when moving from a sitting to a standing position. Which findings should indicate to the nurse that this client may be dehydrated? (Select all that apply.)

Accepted Answer

Symptoms of dehydration can include sudden weight loss, increased heart rate, confusion, tachycardia, and hypotension. Older clients are at an increased risk for dehydration due to blunted thirst perceptions. Edema results from a fluid overload rather than dehydration.
Symptoms of dehydration can include sudden weight loss, increased heart rate, confusion, tachycardia, and hypotension. Older clients are at an increased risk for dehydration due to blunted thirst perceptions. Edema results from a fluid overload rather than dehydration.
Symptoms of dehydration can include sudden weight loss, increased heart rate, confusion, tachycardia, and hypotension. Older clients are at an increased risk for dehydration due to blunted thirst perceptions. Edema results from a fluid overload rather than dehydration.
Symptoms of dehydration can include sudden weight loss, increased heart rate, confusion, tachycardia, and hypotension. Older clients are at an increased risk for dehydration due to blunted thirst perceptions. Edema results from a fluid overload rather than dehydration.

Question 10

An adolescent student visits the school nurse because of feeling nervous and shaky after drinking several cups of coffee and caffeinated soda throughout the day. Which statement should the nurse make to this student?

Accepted Answer

Caffeine can be found in coffee, tea, soft drinks, chocolate, energy drinks, and medicine. Caffeine content on these products will be listed on the ingredient list or content label and should be checked prior to use. Overuse of caffeine can cause serious health problems. Caffeine is a central nervous system stimulant and can cause people to feel irritable and/or shaky. Medications containing caffeine include (but are not limited to) analgesics, cold remedies, and stimulants.

Question 11

A client with poorly controlled hypertension has a blood pressure of 190/96 mm Hg. Which food item should the nurse identify that may have contributed to this elevated measurement?

Accepted Answer

Caffeine is the most widely used central nervous stimulant in the world and can adversely affect blood pressure. Banana, oat meal, and scrambled eggs would not affect blood pressure.

Question 12

The nurse prepares an educational pamphlet on caffeine for a community health fair. Which statements should the nurse include in this material? (Select all that apply.)

Accepted Answer

A high intake of caffeine can cause toxic side effects that include vomiting, seizures, tachyarrhythmias, and even death. There is no evidence that women and adolescents consume the most caffeine in the United States. The amount of caffeine in coffee and tea is affected by the brand, brewing method, and steeping time. Caffeine increases gastric acid production and lowers the esophageal sphincter pressure which can lead to gastroesophageal reflux and gastritis. The amount of caffeine varies between products and can be determined on the ingredient label.
A high intake of caffeine can cause toxic side effects that include vomiting, seizures, tachyarrhythmias, and even death. There is no evidence that women and adolescents consume the most caffeine in the United States. The amount of caffeine in coffee and tea is affected by the brand, brewing method, and steeping time. Caffeine increases gastric acid production and lowers the esophageal sphincter pressure which can lead to gastroesophageal reflux and gastritis. The amount of caffeine varies between products and can be determined on the ingredient label.
A high intake of caffeine can cause toxic side effects that include vomiting, seizures, tachyarrhythmias, and even death. There is no evidence that women and adolescents consume the most caffeine in the United States. The amount of caffeine in coffee and tea is affected by the brand, brewing method, and steeping time. Caffeine increases gastric acid production and lowers the esophageal sphincter pressure which can lead to gastroesophageal reflux and gastritis. The amount of caffeine varies between products and can be determined on the ingredient label.

Question 13

A client who drinks 3 to 4 martinis before dinner every night feels that people who drink beer are alcoholics because of the volume of alcohol in each can. Which response should the nurse make to this client?

Accepted Answer

The average 12-ounce serving of regular beer contains about 14 gm of alcohol. Depending upon the ingredients, a martini will continue much more than 14 gm of alcohol per drink. This client is consuming 3 to 4 martinis each night. Anyone who drinks to excess and is unable to control the desire for alcohol can be considered an alcoholic. It does not make a difference what type of alcohol is consumed.

Question 14

A client who is pregnant with a first child asks if alcohol can be consumed while pregnant. Which response should the nurse make to this client?

Accepted Answer

Alcohol intake during pregnancy is associated with lifelong neurocognitive deficits, behavior problems, and malformation in offspring called fetal alcohol spectrum disorders. No safe level of alcohol intake has been determined that avoids these consequences. The other choices are not appropriate responses regarding ingesting alcohol while pregnant.

Question 15

The nurse notes that several students experience muscle weakness, dizziness, and increased heart rate after cross-country practice. Which action should the nurse take? (Select all that apply.)

Accepted Answer

Dehydration is a risk for athletes who participate in sports which include strenuous physical activity. Arranging a class for school athletes, including information for all students, and discussing fluid needs with the physical education staff would all be good interventions for the nurse. The nurse should not have to be present at all sports events. Emergency personnel does not need to be present for every practice session.
Dehydration is a risk for athletes who participate in sports which include strenuous physical activity. Arranging a class for school athletes, including information for all students, and discussing fluid needs with the physical education staff would all be good interventions for the nurse. The nurse should not have to be present at all sports events. Emergency personnel does not need to be present for every practice session.
Dehydration is a risk for athletes who participate in sports which include strenuous physical activity. Arranging a class for school athletes, including information for all students, and discussing fluid needs with the physical education staff would all be good interventions for the nurse. The nurse should not have to be present at all sports events. Emergency personnel does not need to be present for every practice session.

Question 16

A pregnant adolescent is not gaining weight and reports having a few beers with friends over the weekends. Which response should the nurse make to this client? (Select all that apply.)

Accepted Answer

The intake of any amount of alcohol is not recommended during pregnancy. Alcohol acts as a direct toxin on the developing fetal brain and can cause permanent neurocognitive damage. Alcohol constricts blood vessels and limits the amount of blood flowing to the placenta. Any alcohol ingested during pregnancy can lead to fetal alcohol spectrum disorder which causes physical defects and mental and behavioral disabilities. Binge drinking places the fetus at greatest risk. Criticizing the young woman will close the doors of communication.
The intake of any amount of alcohol is not recommended during pregnancy. Alcohol acts as a direct toxin on the developing fetal brain and can cause permanent neurocognitive damage. Alcohol constricts blood vessels and limits the amount of blood flowing to the placenta. Any alcohol ingested during pregnancy can lead to fetal alcohol spectrum disorder which causes physical defects and mental and behavioral disabilities. Binge drinking places the fetus at greatest risk. Criticizing the young woman will close the doors of communication.
The intake of any amount of alcohol is not recommended during pregnancy. Alcohol acts as a direct toxin on the developing fetal brain and can cause permanent neurocognitive damage. Alcohol constricts blood vessels and limits the amount of blood flowing to the placenta. Any alcohol ingested during pregnancy can lead to fetal alcohol spectrum disorder which causes physical defects and mental and behavioral disabilities. Binge drinking places the fetus at greatest risk. Criticizing the young woman will close the doors of communication.

Question 17

A male client has stopped smoking, plays golf twice a week, and drinks two glasses of wine a night because of learning it is good for the heart. Which response should the nurse make to this client?

Accepted Answer

The current recommendation for alcohol intake is one drink per day for small men and women, whereas two drinks would be considered drinking in moderation for larger men. Moderate intake of alcohol can have some health benefits, but in excess has been linked to cancers, hypertension, depression, insomnia, and disorders of the gastrointestinal tract. Alcohol contains 7 calories/gram and should be identified as a source of calories.

Quiz 8: Fluid, Caffeine, and Alcohol