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 D
Explanation
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis.
The client may or may not need to use the bedpan depending on their fluid intake and output.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis.
The client may or may not need to vomit depending on their underlying condition.
Choice C is wrong because providing oral care every four hours is not enough for a client who has been diaphoretic for the past six hours. The client may have dry mouth and dehydration due to excessive sweating and may need more frequent oral care and hydration.
Correct Answer is D
Explanation
This is because helping the client to recognize and avoid situations that cause anxiety can reduce the frequency and severity of acute anxiety episodes. According to , a nurse should encourage the client to verbalize feelings and provide a calm and supportive environment.
Choice A is wrong because isolating the client when there are observable physiologic symptoms of anxiety can increase the client’s sense of fear and loneliness.
The nurse should stay with the client and offer reassurance and comfort.
Choice B is wrong because ignoring the client’s behavior as obvious attempts to gain attention can make the client feel rejected and misunderstood.
The nurse should acknowledge the client’s feelings and provide empathy and support.
Choice C is wrong because reducing all stress whenever the client seems anxious can prevent the client from learning coping skills and developing resilience.
The nurse should help the client to identify healthy ways of managing stress and anxiety.
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