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 B
Explanation
A. Reduction of the fracture:
Buck's traction is not primarily intended for the reduction (realignment) of the fractured bones. While it may help maintain proper alignment, the primary goal is to provide temporary immobilization and relieve muscle spasms until more definitive treatment, such as surgery, can be performed.
B. Relief from muscle spasms:
This is the correct answer. Buck's traction is commonly used to alleviate muscle spasms associated with hip fractures. The traction force helps to relax the muscles, reduce pain, and maintain the alignment of the fractured bones.
C. Alignment of the pins:
Buck's traction does not involve the insertion of pins into the bone. It uses a boot attached to the leg, and the traction force is applied externally to the limb to achieve the desired therapeutic effects.
D. Support for moving the extremity:
Buck's traction is not intended to support active movement of the extremity. Instead, it provides temporary immobilization to prevent further injury and facilitate the healing process before more definitive interventions, such as surgery, are undertaken.
Correct Answer is B
Explanation
A. “I wish I didn’t have to attach the electrodes to my skin.”
This statement reflects a common sentiment. Attaching electrodes to the skin is part of using TENS, and it's a non-invasive procedure where electrodes are placed on the skin surface to deliver electrical impulses for pain relief.
B. “It’s unfortunate that I have to be in the hospital for this treatment.”
This statement indicates a need for further teaching. TENS is typically an outpatient treatment, and individuals can use TENS units at home after receiving appropriate instructions and training. It does not require being in the hospital.
C. “I’ll need to shave the hair off the skin where I place the electrodes.”
This statement is accurate. To ensure proper contact and effectiveness, it is often recommended to shave or trim the hair in the area where the electrodes will be placed.
D. “I hope I don’t have to take as many pain pills.”
This statement reflects an understanding of the potential benefits of TENS. TENS is used as an adjunct therapy to help manage pain, and one of its goals may be to reduce the need for pain medications.
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