Which focused assessment technique should the nurse use for a client admitted with possible dehydration?

Measure the circumference of the calf.

Grasp skin fold of the posterior forearm.

Check hands for parchment-like appearance.

Press skin over a bony prominence.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Measure the circumference of the calf: Measuring calf circumference is used primarily to assess for deep vein thrombosis (DVT) or edema, not dehydration. It evaluates for swelling but does not give information about the client’s hydration status.

B. Grasp skin fold of the posterior forearm: Checking skin turgor by grasping and gently pulling a fold of skin on the posterior forearm is a standard method to assess for dehydration. Poor turgor, where the skin remains tented, suggests fluid volume deficit and supports a diagnosis of dehydration.

C. Check hands for parchment-like appearance: A parchment-like appearance of the hands is more related to normal aging changes rather than acute dehydration. It reflects thinning of the skin rather than fluid status, and could lead to misinterpretation if used for hydration assessment.

D. Press skin over a bony prominence: Pressing over bony prominences checks for edema or pitting rather than skin elasticity. While edema can coexist with dehydration in complex cases, evaluating turgor is a more direct and sensitive technique for diagnosing dehydration.

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Correct Answer is A

Explanation

Rationale:
A. Paresthesia reported: Paresthesia refers to abnormal sensations like burning, tingling, or numbness, typically due to nerve irritation or damage. Documenting it as "paresthesia reported" is clinically accurate, concise, and uses appropriate medical terminology to communicate the client’s symptom in the EMR.

B. Circulation impaired: Impaired circulation could cause symptoms like coldness, pallor, or numbness, but burning sensations more commonly suggest nerve involvement rather than vascular insufficiency. Labeling it as circulation impairment would not precisely reflect the client’s described symptom.

C. Inflammation present: Inflammation could cause redness, warmth, and swelling, but it is not the primary interpretation of a burning sensation unless there are visible signs of inflammatory response. Without objective evidence, assuming inflammation would be inaccurate documentation.

D. Reports feeling "on fire.": While documenting exact quotes can sometimes be valuable, using clear medical terminology in routine EMR documentation is preferred. "Paresthesia reported" professionally communicates the symptom while maintaining clinical clarity and avoiding subjective descriptions.

A. Axillary nodes feel soft and fatty. B. Inguinal nodes are enlarged and warm to the touch. C. Nodes feel ropey and rubbery. D. Nodes are nonpalpable.

Correct Answer is A

Explanation

Rationale:
A. Axillary nodes feel soft and fatty: In older adults, lymph nodes often become smaller, softer, and more fatty due to age-related atrophy of lymphatic tissue. Soft, fatty nodes in the axillary area are considered a normal finding and generally do not indicate infection or malignancy unless associated with other concerning symptoms.

B. Inguinal nodes are enlarged and warm to the touch: Enlarged and warm lymph nodes suggest acute infection or inflammation. This is not a normal finding at any age and would warrant further evaluation to rule out infectious processes, malignancy, or systemic disease.

C. Nodes feel ropey and rubbery: Ropey and rubbery lymph nodes can indicate abnormal conditions such as lymphoma or chronic infection. While texture can vary, this description is more consistent with pathological changes and not considered normal in a healthy older adult.

D. Nodes are nonpalpable: While nonpalpable lymph nodes can be normal, especially if small and deep, some lymph nodes—like inguinal or axillary nodes—can still be felt even in healthy individuals. Therefore, the presence of soft, fatty nodes is a more typical normal finding rather than complete nonpalpability.

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Which focused assessment technique should the nurse use for a client admitted with possible dehydration?

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