A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit?

Tenting

Protruding eyeballs

Elevated blood pressure

Dry mucous membranes

Answer and Explanation

The Correct Answer is A

A. Tenting

Tenting refers to the delayed recoil of the skin when pinched. In a dehydrated state, the skin loses elasticity, leading to tenting due to decreased skin turgor. This is a specific sign of fluid-volume deficit.

B. Protruding eyeballs

Protruding eyeballs are not typically associated with dehydration. This could be related to other conditions such as thyroid dysfunction, but it is not a specific indicator of fluid-volume deficit.

C. Elevated blood pressure

Elevated blood pressure is not a typical sign of dehydration. In fact, dehydration often leads to a decrease in blood pressure due to reduced blood volume.

D. Dry mucous membranes

Dry mucous membranes can be an indication of dehydration, but in the context of the question, tenting (Option A) is a more specific sign related to skin turgor and is commonly assessed when evaluating for dehydration.

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Correct Answer is C

Explanation

A. Xerostomia

Xerostomia is dry mouth, a condition where the salivary glands do not produce enough saliva. It can have various causes, including medications, medical conditions, or dehydration. Xerostomia is not directly related to teeth grinding.

B. Halitosis

Halitosis is bad breath. While dental issues, including bruxism (teeth grinding), can contribute to bad breath, halitosis itself does not specifically describe teeth grinding.

C. Bruxism

Bruxism is the medical term for teeth grinding or clenching, especially during sleep. If a client suspects or reports grinding their teeth at night, it is appropriate to document and discuss the issue as bruxism. Bruxism can lead to dental problems, jaw pain, and headaches.

D. Sordes

Sordes refers to a collection of foul matter, such as debris or crusted material, around the mouth. It is not related to teeth grinding.

A. “I will call for pain medication before the previous dose wears off.” B. “I will call for pain medication as my pain becomes intolerable.” C. “I will wait for you to evaluate my pain before asking for more.” D. “I will ask for less medication to avoid addiction.”

Correct Answer is A

Explanation

A. “I will call for pain medication before the previous dose wears off.”

The statement "I will call for pain medication before the previous dose wears off" indicates an understanding of proactive pain management. In postoperative pain control, it is generally more effective to stay ahead of the pain by taking pain medication on a scheduled basis rather than waiting until the pain becomes severe. This approach helps to maintain a more consistent level of pain relief.

B. “I will call for pain medication as my pain becomes intolerable.”

Waiting until the pain becomes intolerable may result in suboptimal pain control. It's more effective to take pain medication before reaching a point of intolerable pain.

C. “I will wait for you to evaluate my pain before asking for more.”

Waiting for the nurse to evaluate pain before requesting more medication may result in delays in pain relief. Pain management often involves collaboration between healthcare providers and patients, and timely communication about pain levels is essential.

D. “I will ask for less medication to avoid addiction.”

This statement reflects a concern about addiction but may lead to inadequate pain relief. Pain management should prioritize effective pain control while balancing the risks and benefits of medications. The goal is to provide sufficient pain relief without compromising the client's well-being.

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A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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