The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.
Inspection of lips and mucous membranes.
Pinches the skin on back of the hand.
Measures pulse and blood pressure.
Obtains client's daily weight.
Palpates scalp and hair distribution.
Correct Answer : A,B,C,D
The correct answers are Choices A, B, C, and D.Choice A rationale: Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale: Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale: Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale: Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale: Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.
Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.
Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.
Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.
Choice A is wrong because relationship and evaluation are not techniques of physical assessment.
Relationship refers to the rapport and trust established between the nurse and the patient.
Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.
Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.
They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.
Choice D is wrong because color is not a technique of physical assessment.
Color is an aspect of inspection, which is one of the techniques of physical assessment.
Correct Answer is B
Explanation
120/77 mmHg. This is because this blood pressure reading is within the normal range of less than 120/80 mmHg. Hypertension is defined as a blood pressure of 140/90 mmHg or higher.
Choice A is wrong because 84/50 mmHg is too low and may indicate hypotension, which can cause dizziness, fainting, or shock.
Choice C is wrong because 148/88 mmHg is above the normal range and indicates prehypertension, which is a risk factor for developing hypertension and cardiovascular disease.
Choice D is wrong because 160/90 mmHg is above the normal range and indicates stage 1 hypertension, which requires treatment with lifestyle changes and medication.
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