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. If the apical impulse is more vigorous than expected, it may indicate an abnormal finding, such as hyperdynamic circulation or heart failure. The nurse should not simply record this without further investigation.
B. It is important to investigate whether the client has a history of heart disease, as conditions like left ventricular hypertrophy, heart failure, or valvular heart disease could cause changes in the apical impulse. This provides context for understanding the findings.
C. Obtaining the client’s blood pressure is important in assessing cardiovascular health, but the most immediate response to a more vigorous apical impulse would be to explore the potential cause, including heart disease, rather than simply measuring blood pressure.
D. Comparing the apical pulse to the carotid pulse may help assess if the increased pulse force is generalized or localized, and whether it might be a sign of circulatory changes. This would help clarify whether the finding is normal or indicative of pathology.

A. Absent deep tendon reflexes. B. Capillary refill less than 3 seconds. C. 3+ peripheral dependent edema. D. Oxygen saturation of 85%.

Correct Answer is D

Explanation

A. Absent deep tendon reflexes are not typically associated with nailbed clubbing. While reflexes may be diminished in some conditions, they are not commonly related to the pathophysiology behind clubbing.
B. A capillary refill time of less than 3 seconds is a normal finding and does not align with clubbing, which often indicates chronic hypoxia or systemic conditions such as heart or lung disease.
C. Peripheral dependent edema refers to swelling in the lower extremities, which can be associated with circulatory problems, but it is not directly linked to nailbed clubbing. Edema is more common in conditions like heart failure or kidney disease.
D. A low oxygen saturation of 85% is consistent with conditions that cause chronic hypoxia, such as chronic lung disease or congenital heart disease. Chronic low oxygen levels can lead to nailbed clubbing as a compensatory response to inadequate oxygenation.

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

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Naxlex Comprehensive Predictor Exams

During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Correct Answer is D

Explanation

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