A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Blood pressure 178/90 mm Hg

Edema

Bounding bilateral pulses

Increased urine specific gravity

Answer and Explanation

The Correct Answer is D

A) Blood pressure 178/90 mm Hg: Elevated blood pressure is more commonly associated with fluid overload or hypertension rather than dehydration. In dehydration, one would expect to see a decrease in blood pressure, particularly orthostatic hypotension, due to a reduction in blood volume.

B) Edema: Edema indicates fluid retention in the tissues, which is a sign of fluid overload rather than dehydration. Dehydration typically results in reduced extracellular fluid volume, leading to symptoms like dry mucous membranes and poor skin turgor, rather than swelling.

C) Bounding bilateral pulses: Bounding pulses are usually seen in conditions of increased cardiac output or fluid overload, where there is an excess of fluid volume. In contrast, dehydration often leads to weak and thready pulses due to decreased circulatory volume.

D) Increased urine specific gravity: Increased urine specific gravity is a direct indicator of dehydration. It occurs because the kidneys concentrate urine to conserve water, leading to a higher concentration of solutes in the urine. This is a reliable clinical marker of reduced hydration status, reflecting the body's attempt to maintain fluid balance by conserving water.

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Correct Answer is A

Explanation

A) Popsicle:

A popsicle is appropriate for a clear liquid diet because it is made from clear liquids and does not contain any solids or pulp. Clear liquids are defined as those that are transparent at room temperature, making popsicles a suitable option.

B) Milkshake:

A milkshake is not suitable for a clear liquid diet due to its creamy consistency and solid particles. Clear liquid diets require that all items be transparent and free of any solid components.

C) Orange juice with pulp:

Orange juice with pulp is not appropriate for a clear liquid diet because it contains pulp, which is considered a solid. Clear liquid diets exclude any liquids that have solid components or particulate matter.

D) Yogurt:

Yogurt is not allowed on a clear liquid diet as it contains solids and has a creamy texture. Clear liquid diets are limited to liquids that are completely transparent and free of solids.

A. Edema B. Oliguria C. Hypotension D. Hyperthemia

Correct Answer is A

Explanation

A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.

B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.

C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.

D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature

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