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 C

Explanation

A. Increased intraocular pressure causes glaucoma, not diabetic retinopathy.
B. Clouding of the lens is related to cataracts, not diabetic retinopathy.
C. Seeing spots or floaters is a common symptom of diabetic retinopathy.
D. Diabetic retinopathy requires more frequent eye exams (typically annually) for early detection.

A. Apply an eye patch to the client's right eye. B. Provide range-of-motion exercises to the client's neck and shoulders. C. Avoid the use of warm water to wash the client's face. D. Place suction equipment at the client's bedside.

Correct Answer is D

Explanation

A. While an eye patch may be needed for other conditions (e.g., facial paralysis), it is not a primary concern in this case.
B. Range-of-motion exercises are not related to cranial nerve IX and X impairment.
C. Avoiding warm water to wash the face is not specifically relevant to cranial nerve impairment.
D. Suction equipment should be available for clients with cranial nerve impairment, especially if they have swallowing difficulties or potential for aspiration.

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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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Naxlex Comprehensive Predictor Exams

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