A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit?

Tenting

Protruding eyeballs

Elevated blood pressure

Dry mucous membranes

Answer and Explanation

The Correct Answer is A

A. Tenting

Tenting refers to the delayed recoil of the skin when pinched. In a dehydrated state, the skin loses elasticity, leading to tenting due to decreased skin turgor. This is a specific sign of fluid-volume deficit.

B. Protruding eyeballs

Protruding eyeballs are not typically associated with dehydration. This could be related to other conditions such as thyroid dysfunction, but it is not a specific indicator of fluid-volume deficit.

C. Elevated blood pressure

Elevated blood pressure is not a typical sign of dehydration. In fact, dehydration often leads to a decrease in blood pressure due to reduced blood volume.

D. Dry mucous membranes

Dry mucous membranes can be an indication of dehydration, but in the context of the question, tenting (Option A) is a more specific sign related to skin turgor and is commonly assessed when evaluating for dehydration.

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Correct Answer is C

Explanation

A. Remind the client to tell the nurse when he has to urinate.
Reminding the client may not be effective, as individuals with dementia may have difficulty expressing their needs or may forget to communicate when they need to use the bathroom. It relies on the client's ability to remember and communicate.

B. Use adult diapers to prevent frequent clothing changes.
While adult diapers can be part of a comprehensive plan for managing incontinence, they should not be the sole intervention. Relying solely on diapers does not address the underlying causes of incontinence and may not promote optimal dignity and quality of life.

C. Take the client to the bathroom on an every-2-hr schedule.
This is the correct choice. Taking the client to the bathroom on a regular schedule (timed voiding) is a proactive approach to managing urinary incontinence in individuals with dementia. It helps reduce the likelihood of accidents by ensuring regular opportunities for toileting.

D. Request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters are generally not recommended for managing routine urinary incontinence due to the associated risks, including infection. Catheters should be used judiciously and based on medical necessity.

A. The ropes are in the center of the wheel grooves. B. The weights rest against the foot of the bed. C. The weights are equal on each side. D. The ropes attach securely to the pin.

Correct Answer is B

Explanation

A. The ropes are in the center of the wheel grooves.

Having the ropes in the center of the wheel grooves is appropriate and ensures proper alignment within the pulley system. This is not a problem that needs correction.

B. The weights rest against the foot of the bed.

This is the correct choice for correction. Allowing the weights to rest against the foot of the bed can alter the amount of force applied to the skeletal structures and compromise the effectiveness of the traction. The weights should hang freely and move within the pulley system.

C. The weights are equal on each side.

Having equal weights on each side is generally appropriate and helps maintain proper balance in the traction system. This is not a problem that needs correction.

D. The ropes attach securely to the pin.

Secure attachment of the ropes to the pin is essential for maintaining proper traction. This is not a problem that needs correction if the attachment is secure.

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A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Correct Answer is C

Explanation

A client returns to the surgical unit from the PACU in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup?

Correct Answer is B

Explanation

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