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 A

Explanation

A. "Eating yogurt can help decrease gas odor that I have."
This is the correct choice. Yogurt contains probiotics, which can contribute to a healthy balance of bacteria in the digestive system, potentially reducing gas odor associated with a colostomy.

B. "I should eliminate pasta from my diet so that I don’t have as many loose stools."
This statement is incorrect. Pasta, as a general rule, is not associated with causing loose stools. Dietary adjustments should be individualized, and specific triggers for loose stools vary among individuals.

C. "My largest meal of the day should be in the evening."
While meal timing can vary based on personal preferences and lifestyle, there is no strict rule that the largest meal must be in the evening. It depends on individual habits and dietary needs.

D. "Carbonated beverages can help control odor."
This statement is incorrect. Carbonated beverages are not typically associated with controlling odor related to a colostomy. In fact, they may contribute to increased gas production, potentially exacerbating odor issues.

A. Keep the prosthesis in direct contact with the residual limb. B. Apply a moisturizing lotion or oil to the stump daily. C. Dry the prosthesis socket completely before applying it to the limb. D. Expect some skin irritation from the prosthesis.

Correct Answer is C

Explanation

A. Keep the prosthesis in direct contact with the residual limb.

This statement is incorrect. Prosthetic care typically involves using a liner or sock between the residual limb and the prosthesis. This helps to provide cushioning, absorb sweat, and reduce friction, contributing to comfort and preventing skin irritation.

B. Apply a moisturizing lotion or oil to the stump daily.

Moisturizing the skin on the residual limb is generally advisable to prevent dryness and irritation. However, it's crucial to ensure that the skin is completely dry before attaching the prosthesis. Moisturizing can help maintain skin health and comfort.

C. Dry the prosthesis socket completely before applying it to the limb.

This statement is correct. Ensuring that the prosthesis socket is thoroughly dry before application is crucial to prevent skin irritation and ensure a secure fit. Moisture between the skin and the prosthesis can contribute to discomfort and skin-related issues.

D. Expect some skin irritation from the prosthesis.

While it is common to experience minor skin irritation initially as the individual adjusts to the prosthesis, persistent or severe irritation should be addressed. The goal is to achieve a proper fit and minimize skin-related problems through appropriate care and adjustments.

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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

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A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements by the client indicates an understanding of the dietary teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about prosthesis care for a client following a below-the-knee amputation. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

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