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
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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Related Questions
Correct Answer is C
Explanation
A. The stockings are used to reduce pain.
This statement is not accurate. While antiembolism stockings may provide some relief from discomfort and swelling, their primary purpose is to prevent venous stasis and reduce the risk of blood clots, not to directly reduce pain.
B. The stockings prevent varicose veins.
This statement is not entirely accurate. While compression stockings can provide some support to veins, their primary role is in preventing blood clots (venous thromboembolism) rather than preventing varicose veins, which are typically related to venous insufficiency.
C. The stockings prevent venous stasis.
This is the correct answer. Antiembolism stockings are specifically designed to prevent venous stasis, which refers to the slowing or stagnation of blood flow in the veins. They exert gentle pressure on the legs to enhance blood circulation and reduce the risk of blood clots.
D. The stockings replace the need for postoperative leg exercises.
This statement is not accurate. While antiembolism stockings are a preventive measure, they do not replace the need for postoperative leg exercises. Leg exercises are important for promoting circulation, preventing complications such as deep vein thrombosis (DVT), and maintaining overall mobility after surgery.
Correct Answer is B
Explanation
A. Rub the client’s feet briskly for several minutes.
Rubbing the feet briskly may not be appropriate for a client with vascular occlusion. Vigorous rubbing could potentially cause damage to already compromised blood vessels, and the increased friction may not be well-tolerated.
B. Obtain a pair of slipper socks for the client.
Providing slipper socks is a non-invasive and appropriate measure to help keep the client's feet warm. Slipper socks can offer comfort without the need for vigorous interventions or potential harm. They provide insulation and can be easily applied.
C. Increase the client’s oral fluid intake.
While staying well-hydrated is generally important for overall health, increasing oral fluid intake may not directly address the specific issue of cold feet associated with vascular occlusion. It is essential to address the underlying circulatory issue causing the symptom.
D. Place a moist heating pad under the client’s feet.
Applying heat, especially in the form of a moist heating pad, may not be recommended for a client with vascular occlusion. Heat can dilate blood vessels and potentially exacerbate the issue by increasing blood flow to the compromised extremity. It's important to avoid interventions that could worsen the vascular compromise.
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