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 B

Explanation

A. Intact skin with localized erythema: This describes a stage 1 pressure injury.
B. Partial-thickness skin loss with red tissue in wound bed: This is characteristic of stage 2 pressure injuries, where there is damage to the epidermis and partial dermis.
C. Full thickness skin loss with visible adipose tissue: This describes a stage 3 pressure injury.
D. Full thickness skin loss with visible bone: This describes a stage 4 pressure injury.

A. Exposed bone B. Blood filled blisters C. Necrotic subcutaneous tissue D. Partial-thickness skin loss

Correct Answer is C

Explanation

A. Exposed bone refers to a stage 4 pressure ulcer, which involves full-thickness tissue loss with bone, muscle, or tendon exposure.
B. Blood-filled blisters are more indicative of a stage 2 ulcer, which involves partial-thickness skin loss with blister formation.

C. A stage 3 ulcer is characterized by full-thickness skin loss, with damage extending into subcutaneous tissue, where necrosis may occur.
D. Partial-thickness skin loss is a characteristic of a stage 2 pressure ulcer, not stage 3.

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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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