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 D
Explanation
A. “I don’t take naps throughout the day.”
This statement suggests that the client avoids daytime napping, which is generally a positive sleep habit. Excessive daytime napping can interfere with nighttime sleep.
B. “I go to bed and get up at the same times each day.”
Maintaining a consistent sleep schedule is a key component of good sleep hygiene. Going to bed and waking up at the same times helps regulate the body's internal clock.
C. “I have a small snack and take a bath before going to bed each day.”
Having a light snack and engaging in a relaxing activity like a bath before bedtime can contribute to a more conducive sleep environment. However, the type and timing of the snack should be considered.
D. “I watch television until I fall asleep at night.”
This statement may indicate a need for further instruction. Watching television right before bedtime, especially until falling asleep, can be counterproductive to good sleep hygiene due to the stimulating effects of the screen's blue light.
Correct Answer is C
Explanation
A. Assign an assistive personnel to feed the client.
This option involves assigning someone else to feed the client. While it may ensure that the client receives adequate nutrition, it does not promote independence. The client may prefer to feed themselves if given the opportunity.
B. Explain that the tray is here and place the client’s hands on the tray.
While explaining the presence of the tray is helpful, physically placing the client's hands on the tray is a more direct form of assistance. It takes away the opportunity for the client to explore and locate items independently.
C. Describe to the client the location of the food on the tray.
This is the correct choice. Describing the location of the food on the tray allows the client to use their remaining senses, such as touch and hearing, to independently locate and eat their food.
D. Ask the client if she would prefer a liquid diet.
This option is related to dietary preferences but does not directly address the issue of promoting independence in eating. It focuses more on the type of diet rather than the manner in which the client can independently manage their meals.
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