A nurse is performing an admission assessment on an older patient who presented with a high fever and cough, reduced oral intake for 3 days, and lower extremity weakness.
The patient has sunken eyes, and the patient's skin turgor over the sternum is poor. The nurse suspects that the patient is dehydrated. Which of the following are indicators of dehydration in this patient? (Select all that apply.)
a. Poor skin turgor over the sternum
b. Lower extremity weakness
c. High fever
d. Sunken eyes
e. Cough
Question 2An older adult complains of xerostomia. Which of the following interventions should the nurse implement for this patient? (Select all that apply.)
a. Encourage the patient to brush and floss teeth regularly.
b. Encourage the patient to have regular dental screenings.
c. Provide antiseptic mouthwash (e.g., Lis-terine) for the patient.
d. Encourage adequate intake of water.
e. Provide saliva substitutes.
Question 3A nurse is observing a nurse aide perform denture care for a resident in the nursing home. The nurse recommends that the nurse aide receive additional education on denture care when the nurse observes which of the following?
a. The nurse aide places a face cloth in the sink and fills the sink half full with water.
b. The nurse aide uses toothpaste to clean the dentures.
c. The nurse aide utilizes a specially designed denture brush to clean the dentures.
d. The nurse aide stores the dentures in a denture cup filled with denture cleansing solution.
Question 4In a long-term care facility, a nurse is having a discussion with the nurse aides about ways to deal with dementia clients who are uncooperative with mouth care. Appropriate methods to use in-clude:
a. speaking to the client sternly and instruct-ing the client to open the mouth and co-operate immediately.
b. having another nurse aide assist in holding the client's mouth open with a tongue de-pressor.
c. involving the client in the process of oral hygiene, such as using the hand over hand technique to brush the client's teeth.
d. quickly performing oral hygiene without explanation since the client is uncoopera-tive.
Question 5Which of the following are age-related changes that affect hydration status? (Select all that ap-ply.)
a. Decrease in thirst sensation
b. Decrease in total body water
c. Decrease in ability of kidneys to maxi-mally concentrate urine
d. Decrease in bone marrow mass
e. Decrease in bladder capacity
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