Edapt Nursing Application: Water and Wellness

The community-based living center had a water filtration unit installed. Which sodium sensitive client should the nurse carefully observe? Select all that apply.

-client with congestive heart failure -client taking lithium

An older adult who is normally alert and oriented has become increasingly confused for no apparent reason. The nurse plans to conduct a focused assessment to assess the client for which alteration in health that may the cause of the confusion?

Dehydration

Mr. Smith is being discharged home on a low sodium diet. Which statement made by this client indicates that additional education on preventing fluid volume excess is needed?

"I will eat pretzels instead of salted nuts"

During a follow up visit Jill shares that her partner recently lost his job, and the family is struggling to pay rent and keep food on the table. When explaining how the family continues to assure their children have an adequate intake of clean water, which statement made by Jill shows a need for further teaching.

"We can use cold unfiltered water to make baby formula"

Jill's stool sample was positive for bacterial gastroenteritis, and her parents are taking her home today. What information should the nurse include in discharge teaching? Select all that apply.

-importance of good hand washing to prevent spread of infection -tell them when to contact the health care provider -rehydration plan - add 4-8 oz of plain water to Jill's daily intake -teach early signs of dehydration

When discussing outcomes of care with an adult client recovering from fluid volume deficit (FVD), the nurse explains that the client should see what indicators that their condition is improving? Select all that apply.

-increasing urine output -light-colored urine -decreasing thirst

The 3 major compartments that contain fluid in the body are ____, ____, and ____. The body maintains a state of ____ by shifting fluid between these three compartments. The major electrolytes responsible for shifting fluid between compartments are ____ and ____. An increase in sodium intake can result in ____. While a dry mouth is a symptom of ____.

-intravascular -interstitial -intracellular -homeostasis -sodium -potassium -fluid volume excess -fluid volume deficit

The nurse is assessing Jill, a 6-month-old infant is seen in the emergency department with vomiting and diarrhea. Which documented data indicates that the infant is experiencing altered fluid balance? Select all assessment data that applies.

-vomiting -diarrhea -dry mucous membranes -poor skin turgor -sunken fontanel -100.4 temp

After completing the initial assessment, what additional information should the nurse obtain to determine the severity of the infant's condition? Select all that apply.

-weight at last check-up -number of diapers used in last 24-hours -current weight -color of urine -time of last diaper change -has time spent sleeping increased

When assessing a 2-year-old whose parent reports "something is not quite right" the nurse associates which assessment findings with fluid volume excess? Select all that apply.

-weight gain -distended abdomen -dyspnea

The nurse selected three nursing diagnoses to address Jill's current needs. How should the nurse prioritize them? Move items to order from highest to lowest priority.

1. fluid volume deficit related to frequent loose diarrhea stools and vomiting 2. altered nutrition: less than body requirements related to inadequate oral intake 3. Risk for infection as evidence by low grade fever and vomiting and diarrhea

An adult who weighs 50 pounds completed a radiologic procedure with contrast. The client ask how much additional water they should drink to flush the contrast dye from the client's body. The nurse advises the client to drink and additional 40 mL of water per kilogram of body weight. How much fluid should the client consume?

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Based on the priority diagnosis of fluid volume deficit, select 2 anticipated actions to be taken by the nurse (left column) and two expected outcomes of care (right column) for Jill

Anticipated Actions: stool culture, administer IV fluids Expected Outcomes: soft formed stools within 24 hours, urine specific gravity 1.002-1.006

The home health nurse is assessing an older adult living with moderate cognitive impairment. Based on the intake and output record recorded by the client's live-in care giver, what should the nurse identify as the priority health concern?

Anticipated Change in Behavior: ? Priority Health Concern: ? Client Education: ? The priority nursing intervention is to offer the client fluids every two hours. The client has dementia, so the client will not respond to the thirst sensation or comprehend the education.

While assessing an older adult who has developed muscle cramps, the nurse observes the client has chapped lips, a dry tongue, and a rapid, steady pulse. Which action should the nurse take next?

Obtain orthostatic vital signs

The nurse is caring for several residents in a skilled nursing facility. New protocols were put in place to reduce the instances of dehydration in the residents. Which client will the nurse closely assess for dehydration?

The individual with dry lips and 3-pound weight loss in the past 24 hours.