An older adult who is a non-Hispanic Caucasian has a fasting blood sugar level above 130 mg/dL. Which client assessment does the nurse use to confirm a high risk for diabetes mellitus in the client?

Choice A reason: This is a correct answer because heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. This can cause fluid retention and congestion in the lungs, kidneys, and other organs. Heart failure can also affect the thirst mechanism and the secretion of antidiuretic hormone, which can lead to reduced fluid intake and increased fluid loss. Therefore, heart failure can increase the risk of dehydration in older clients.

Choice B reason: This is a correct answer because nonfunctional impairments are limitations in the ability to perform activities of daily living, such as bathing, dressing, or toileting. Nonfunctional impairments can be caused by various factors, such as cognitive decline, mobility problems, or sensory loss. Nonfunctional impairments can affect the access to fluids, the awareness of thirst, or the ability to swallow. Therefore, nonfunctional impairments can increase the risk of dehydration in older clients.

Choice C reason: This is a correct answer because longitudinal furrows on the tongue are signs of dehydration in older clients. The tongue is a mucous membrane that can reflect the hydration status of the body. Dehydration can cause the tongue to lose its moisture and elasticity, and develop cracks or fissures along its length. Therefore, longitudinal furrows on the tongue can indicate dehydration in older clients.

Choice D reason: This is an incorrect answer because hypertension is not an issue that might put your client at risk for dehydration, but rather a complication of dehydration. Hypertension is the elevation of the blood pressure above the normal range, which can damage the blood vessels and increase the risk of cardiovascular disease. Hypertension can be caused by various factors, such as aging, obesity, smoking, stress, or kidney disease. Dehydration can also cause hypertension, as the loss of fluid can reduce the blood volume and increase the blood viscosity and concentration of sodium. Therefore, hypertension is not a risk factor for dehydration, but a consequence of dehydration.

Choice A reason: This action is correct because the client is showing signs of a possible stroke, such as a severe headache and numbness in one side of the body. The nurse should call 9-11 immediately to get the client to the nearest hospital for urgent evaluation and treatment. The nurse should also monitor the client's vital signs, neurological status, and airway until help arrives.

Choice B reason: This action is incorrect because the client's headache and numbness are not likely to be caused by a migraine, but by a stroke. The nurse should not waste time asking about the client's history of headaches, but rather act quickly to get the client to the hospital. The nurse should also not assume that the client's symptoms are benign or familiar, but rather treat them as an emergency.

Choice C reason: This action is incorrect because the client's headache and numbness are not likely to be relieved by acetaminophen, but by a stroke. The nurse should not give the client any medication without a doctor's order, especially if the client has a history of TIA or stroke. The nurse should also not delay calling 9-11 by administering medication, as every minute counts in saving the client's brain cells.

Choice D reason: This action is incorrect because the client's headache and numbness are not likely to resolve within 24 hours, but by a stroke. The nurse should not reassure the client that the symptoms are temporary or harmless, but rather alert the client that they are signs of a serious condition. The nurse should also not delay calling 9-11 by providing false comfort, as the client's condition may worsen rapidly.