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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Set the pad’s temperature to 42.2° C (108 F).
The specific temperature setting for a heat application should be based on the healthcare provider's prescription and the therapeutic goals. The temperature should be within a safe and therapeutic range.
B. Stop the treatment if the client’s skin becomes red.
This is the correct choice. Redness on the skin during heat application may indicate potential skin irritation or the onset of a burn. Stopping the treatment if redness occurs is crucial to prevent further injury.
C. Leave the pad in place for at least 40 min.
The duration of heat application should also be based on the healthcare provider's prescription and therapeutic goals. Leaving the pad in place for a specific duration is important, but the exact time would depend on the therapeutic plan.
D. Use safety pins to keep the pad in place.
Safety pins should not be used to secure heat applications, as they can pose a risk of injury. Instead, healthcare professionals should use the appropriate securing devices provided with the heat application or follow facility protocols.
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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