Nokea
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.
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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.
Which hormone is made in the pituitary gland and increases water absorption in the kidney?
- A. Intracellular fluid
- B. Interstitial fluid
- C. Plasma
- D. ADH
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How would a decrease in blood protein concentration impact the fluid volumes?
- A. increase interstitial fluid volume.
- B. decrease blood plasma volume.
- C. decrease interstitial fluid volume.
- D. increase interstitial fluid volume and decrease blood plasma volume.
Correct Answer: D
Rationale: A decrease in blood protein concentration would lead to a reduction in osmotic pressure, which is responsible for drawing fluid back into the capillaries. This decrease in osmotic pressure would result in an increase in interstitial fluid volume as fluid moves out of the capillaries, and a decrease in blood plasma volume as less fluid is drawn back into the circulation. Therefore, the correct answer is to increase interstitial fluid volume and decrease blood plasma volume. Choices A, B, and C are incorrect because they do not reflect the impact of decreased blood protein concentration on fluid volumes.
You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health?
- A. Nutritional status
- B. Potassium balance
- C. Calcium balance
- D. Fluid volume status
Correct Answer: D
Rationale: Assessing the specific gravity in a patient with SIADH helps the nurse evaluate the patient's fluid volume status. Specific gravity indicates the concentration of solutes in the urine and can detect if the patient has a fluid volume deficit or excess. Nutritional status, potassium balance, and calcium balance are not directly assessed through specific gravity testing. Nutritional status is typically evaluated through dietary intake and anthropometric measurements. Potassium balance is assessed through blood tests and ECG monitoring. Calcium balance is evaluated through blood tests and bone density scans. Therefore, the correct answer is assessing fluid volume status through specific gravity testing.
What is the function of aldosterone?
- A. Regulates body temperature.
- B. Decreases blood pressure.
- C. Increases sodium reabsorption.
- D. Promotes water excretion.
Correct Answer: C
Rationale: Aldosterone increases the reabsorption of sodium in the kidneys, which leads to an increase in blood volume and blood pressure. Choice A is incorrect as aldosterone does not regulate body temperature. Choice B is incorrect as aldosterone increases blood pressure by increasing sodium reabsorption. Choice D is incorrect as aldosterone promotes water retention by increasing sodium reabsorption.