MCA Exam 1 (Already Passed with 100% correct answers)

What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused? 1. risk of dehydration 2. risk of kidney damage 3. risk of stroke 4. risk of bleeding correct answers Answer: 1 Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality. Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & electrolyte issues. Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues. Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues. The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for developing? 1. intracellular fluid deficit 2. intracellular fluid overload 3. extracellular fluid deficit 4. interstitial fluid deficit correct answers Answer: 1 Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following? 1. the body's natural compensatory mechanisms 2. pharmacological effects of a diuretic 3. effects of rapidly infused intravenous fluids 4. cardiac failure correct answers Answer: 1 Rationale 1: The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain & heart.