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

Skin tenting present

Low body temperature

Blood pressure 178/90 mm Hg

Jugular vein distention

Answer and Explanation

The Correct Answer is A

A.   Skin tenting, where the skin remains pinched after being pulled up, is a classic sign of dehydration due to a lack of adequate fluid in the tissues.
B.   Low body temperature is not typically associated with dehydration; instead, a fever or elevated temperature is more commonly seen with infection.
C.   High blood pressure (178/90 mm Hg) could indicate hypertension or another condition, but it is not a direct sign of dehydration.
D.   Jugular vein distention is more commonly associated with fluid overload, heart failure, or other circulatory issues, rather than dehydration.

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Correct Answer is A

Explanation

A. "Silvery, white scales": This is the classic presentation of psoriasis, a chronic skin disorder that results in the rapid turnover of skin cells, leading to thick, scaly patches, usually on the scalp, elbows, and knees.
B. Serous drainage: This is more common in conditions like infected wounds or abscesses, not psoriasis.
C. Intense pain: Psoriasis can cause discomfort, but it is typically not painful unless there are complications such as cracks or secondary infections.
D. Unilateral lesions: Psoriasis typically affects both sides of the body symmetrically, not unilaterally.

A. Ask the client to identify scented aromas. B. Listen to the client's speech. C. Ask the client to clench his teeth. D. Ask the client to read a Snellen chart.

Correct Answer is D

Explanation

A. Ask the client to identify scented aromas: This assesses cranial nerve I (olfactory), not cranial nerve II.
B. Listen to the client's speech: This assesses cranial nerve IX and X (glossopharyngeal and vagus), not cranial nerve II.
C. Ask the client to clench his teeth: This assesses cranial nerve V (trigeminal), not cranial nerve II.
D. Ask the client to read a Snellen chart: This is the correct method for assessing cranial nerve II (optic), which is responsible for vision. The Snellen chart tests visual acuity.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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