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. Reposition the client every 2 hr: This is an essential action to prevent pressure ulcers and skin breakdown, especially for bedridden patients. Frequent repositioning helps alleviate pressure on bony prominences.
B. Assess the client's skin for increased coolness: While assessing skin temperature is important, it is not as immediate as repositioning the patient. Increased coolness may suggest poor circulation.
C. Keep the client's skin moist: Keeping the skin moist can lead to skin breakdown and increases the risk for pressure ulcers. Dry skin is typically preferred to avoid moisture-related damage.
D. Massage the client's red bony prominences: Massaging reddened skin can actually damage the tissue and worsen pressure injuries. It is advised to avoid massaging bony prominences that show signs of pressure.

A. Testing visual acuity B. Eliciting the gag reflex C. Observing for facial symmetry D. Checking the pupillary response to light

Correct Answer is D

Explanation

A. Testing visual acuity: This assesses cranial nerve II (optic), not cranial nerve III.
B. Eliciting the gag reflex: This assesses cranial nerve IX and X (glossopharyngeal and vagus), not cranial nerve III.
C. Observing for facial symmetry: This assesses cranial nerve VII (facial nerve), not cranial nerve III.
D. Checking the pupillary response to light: Cranial nerve III (oculomotor) is responsible for controlling pupil constriction in response to light, making this the correct method to assess cranial nerve III.

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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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