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 D

Explanation

A) Speech Therapist: A speech therapist typically works with clients who have communication or swallowing disorders. While they may be involved in assessing and managing difficulties with swallowing, they are not the primary professionals for addressing issues related to hand function or fine motor skills, which are crucial for self-feeding in clients with rheumatoid arthritis.

B) Registered Dietician: A registered dietician is responsible for assessing and planning nutritional needs, which may include recommending dietary modifications for overall health and well-being. However, they do not specifically address the mechanical or functional aspects of eating, such as difficulties due to pain and hand deformities in rheumatoid arthritis.

C) Physical Therapist: Physical therapists focus on improving gross motor function, mobility, and physical strength. While they may help with general mobility and exercise plans to reduce pain and improve joint function, they are not specialists in the fine motor skills and adaptive strategies needed for activities of daily living, such as self-feeding.

D) Occupational Therapist: Occupational therapists specialize in helping clients regain and improve their ability to perform daily activities, particularly those involving fine motor skills. They are well-suited to address issues like pain management, joint protection techniques, and the use of adaptive equipment for self-feeding in clients with rheumatoid arthritis. They work on enhancing the client’s functional independence despite physical limitations.

A. 8 hr B. 4 hr C. 6 hr D. 2 hr

Correct Answer is D

Explanation

A. 8 hr - Infusing one unit of packed red blood cells (PRBCs) over 8 hours is too long. Typically, PRBCs are infused over a shorter period to avoid complications.

B. 4 hr - Infusing PRBCs over 4 hours is still within acceptable limits, but the standard time for PRBC transfusion is usually shorter.

C. 6 hr - Infusing PRBCs over 6 hours is longer than usual. The recommended duration for infusing one unit of PRBCs is generally shorter.

D. 2 hr - The standard time to infuse one unit of PRBCs is typically between 1.5 to 2 hours. This duration helps ensure the effective delivery of red blood cells while minimizing the risk of transfusion reactions.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with rheumatoid arthritis. The client is having difficulty with self-feeding due to the pain and hand deformities. The nurse would anticipate a referral will be made to which member of the interprofessional team?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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