When assessing an older adult client, which finding is most indicative of dehydration?

Tenting noted in subclavicular area.

Loss of skin elasticity in the hand.

Skin is warm and dry.

Thinning hair in the lower extremities.

Answer and Explanation

The Correct Answer is A

A.   Skin tenting is a sign of dehydration. It occurs when the skin, after being pinched, does not quickly return to its normal position. This is often seen in areas with loose skin such as the subclavicular region.
B.   Loss of skin elasticity is a normal aging process and not specifically indicative of dehydration. It can be seen in older adults regardless of hydration status.
C.   Warm and dry skin can be a sign of dehydration. Dehydration leads to reduced sweating, which can result in dry skin, and it may also increase the body temperature, making the skin feel warm.
D.   Thinning hair, especially in the lower extremities, is typically associated with circulatory issues or aging. It is not a direct sign of dehydration.

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Correct Answer is B

Explanation

A. Facial asymmetry may indicate neurological issues, but it does not directly assess the stuporous state.
B. A stuporous state is characterized by a reduced level of consciousness, and the nurse should assess
the client’s response to stimuli to confirm the report of stupor.
C. A positive Romberg sign indicates a balance issue, but it is not directly related to confirming a stuporous state.
D. While pupillary response is important, it does not provide sufficient information to confirm a stuporous state without assessing responsiveness to stimuli.

A. Screen client for alcohol or controlled drug abuse. B. Evaluate client for side effects of routine medications. C. Instruct client to demonstrate activities of daily living. D. Focus questions to evaluate long term memory.

Correct Answer is C

Explanation

A. Alcohol or drug abuse screening may be important but does not directly assess functional ability.
B. Medication side effects can impact functionality, but ADLs are a direct measure of independence.
C. Assessing a client's ability to perform activities of daily living (ADLs) is crucial for determining their functional status and whether they can live independently or need assistance.
D. Long-term memory evaluation is less important than assessing the client's ability to perform daily tasks.

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When assessing an older adult client, which finding is most indicative of dehydration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Correct Answer is B

Explanation

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Correct Answer is C

Explanation

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

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