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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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.
Correct Answer is B
Explanation
This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.
Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.
Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.
Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.
Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.
Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.
Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.
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