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 D

Explanation

A. Cranial nerve V (trigeminal) is not directly related to ataxia or balance. It is more involved in sensory perception of the face and motor function for chewing.
B. Kernig's sign is a test for meningitis, not ataxia or balance issues. It involves flexing the hips and knees to check for resistance or pain that may suggest meningeal irritation.
C. Clubbing is related to chronic oxygenation issues or respiratory/cardiovascular conditions, but it is not a direct assessment of ataxia or balance.
D. A Romberg's test is used to assess balance and proprioception. By having the client stand with feet together and eyes closed, the nurse can assess the client's ability to maintain balance and identify any unsteadiness or ataxia that may impair safe ambulation.

A. Have the client identify specific smells. B. Check the client's visual acuity using a Snellen chart. C. Observe for the ability of the client to turn their head side to sidê. D. Whisper in one of the client's ears while occluding the other.

Correct Answer is C

Explanation

A. Identifying specific smells checks cranial nerve I (olfactory).
B. Checking visual acuity with a Snellen chart assesses cranial nerve II (optic).
C. Observing for the ability to turn the head side to side tests cranial nerve XI (accessory), which controls the sternocleidomastoid and trapezius muscles responsible for head movement.
D. Whispering in one ear while occluding the other tests cranial nerve VIII (vestibulocochlear).

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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?

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