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","B","C","E"]

Explanation

A. The groin area is prone to skin breakdown due to friction, moisture, and pressure, especially in immobile patients.
B. The coccyx (tailbone) is a high-risk area for pressure ulcers due to constant pressure when sitting, particularly in bedridden patients.
C. The heels are vulnerable to pressure ulcers because they are under constant pressure when lying down or when standing for prolonged periods.
D. While the scapula may be at risk in certain conditions (e.g., if the patient is immobile and lying on their back), it is generally not as high-risk as other areas like the coccyx or heels.
E. This area is at risk due to moisture, friction, and pressure from the breast tissue, especially in obese or immobile patients.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

Correct Answer is C

Explanation

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