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 B

Explanation

A. "I will rest for at least 30 minutes before eating."
This statement is appropriate. Resting before meals can help conserve energy and reduce dyspnea (shortness of breath) during eating for individuals with COPD.

B. "I will drink plenty of beverages with my meals."
This statement indicates a need for further teaching. Excessive fluid intake during meals can contribute to feelings of fullness and increase the risk of bloating, making it more difficult for the client with COPD to breathe comfortably.

C. "I will eat five or six small meals each day."
This statement is appropriate. Eating smaller, more frequent meals can help prevent overdistension of the stomach and reduce the feeling of fullness, making it easier for the client to breathe.

D. "I will increase my intake of protein."
This statement is appropriate. Adequate protein intake is important for individuals with COPD to support respiratory muscle function and overall nutritional status.

A. “Skeletal traction has less risk for infection than skin traction.” B. “Clients in skin traction have more mobility than those in skeletal traction.” C. “Skeletal traction is better than skin traction for reducing a fracture.” D. “Clients in skin traction have more discomfort than those in skeletal traction.”

Correct Answer is C

Explanation

A. "Skeletal traction has less risk for infection than skin traction."

This statement is not accurate. Both skeletal and skin traction carry some risk of infection, but the risk factors and considerations are different for each. Skeletal traction involves pins or wires directly inserted into the bone, and while the risk of infection is present, it is not necessarily lower than that of skin traction.

B. "Clients in skin traction have more mobility than those in skeletal traction."

This statement is not accurate. Skeletal traction, involving the use of weights and pins or wires inserted into the bone, tends to provide more stable immobilization. Skin traction, which relies on external devices applied to the skin's surface, may allow for some limited mobility but is generally not as effective as skeletal traction.

C. "Skeletal traction is better than skin traction for reducing a fracture."

This is the correct statement. Skeletal traction is often more effective in providing a stable and controlled environment for reducing and immobilizing fractures.

D. "Clients in skin traction have more discomfort than those in skeletal traction."

This statement is not necessarily accurate. Discomfort can vary depending on the individual, the type of fracture, and other factors. Both skeletal and skin traction may cause some discomfort, and it's important to assess and manage the client's pain appropriately in either case.

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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

A nurse is reinforcing teaching for a client who has COPD. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

Correct Answer is C

Explanation

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