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 A
Explanation
A. Discuss a referral to home health and hospice care with the client and family.
This is the correct answer. Discussing a referral to home health and hospice care addresses the client's expressed desire to go home and provides the necessary support and care for both the client and the family during this challenging time.
B. Contact the social worker to assist with nursing home placement.
This option may not align with the client's wish to go home. Nursing home placement may not be the preferred choice, especially when the client wants to spend their final days in a home setting.
C. Talk with the provider about extending the client’s hospital stay.
Prolonging the hospital stay may not meet the client's expressed wish to go home and may not provide the same level of comfort and support as home health and hospice care.
D. Instruct the family about meeting the client’s palliative care needs at home.
While providing information about meeting palliative care needs at home is important, it is more comprehensive to involve home health and hospice services, which can provide skilled care, emotional support, and assistance to the family in managing the client's care needs at home.
Correct Answer is A
Explanation
A. Check that the client lifts the walker and then places it down in front of her.
To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.
B. Walk in front of the client to guide her in moving the walker.
The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.
C. Have the client move one leg forward with the walker.
The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.
D. Make sure that the upper bar of the walker is level with the client’s waist.
The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.
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