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. "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.
Correct Answer is B
Explanation
A. Offer to request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters carry risks, including the risk of infection, and should not be used solely for the purpose of addressing the fear of falling. Catheter use should be based on medical necessity.
B. Keep a night light on in the client’s room.
This is the most appropriate action. Keeping a night light on can help the client navigate the new surroundings more safely and reduce the risk of falls due to disorientation.
C. Limit the client’s fluid intake in the evening.
Limiting fluid intake, especially in the absence of a medical indication, may lead to dehydration and is not the best solution for addressing the fear of falling.
D. Put the side rails up and tell the client to call for assistance to the bathroom.
While encouraging the client to call for assistance is important, putting all four side rails up can be considered a restraint. Restraints should be avoided whenever possible to promote mobility and independence. It's important to balance safety with maintaining the client's autonomy.
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