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. Provide a diet high in protein.
During the oliguric phase of acute kidney injury (AKI), there is a risk of electrolyte imbalances, including elevated levels of blood urea nitrogen (BUN) and creatinine. Restricting protein intake is often recommended during this phase to manage azotemia and prevent the accumulation of waste products that the kidneys may struggle to excrete.
B. Provide ibuprofen for retroperitoneal discomfort.
Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in AKI. They can further compromise renal function and may contribute to acute tubular necrosis. NSAIDs can also affect renal blood flow, leading to worsening kidney function.
C. Monitor intake and output hourly.
Monitoring intake and output (I&O) is a critical nursing intervention during the oliguric phase of AKI. Hourly monitoring helps assess renal function, fluid balance, and the effectiveness of interventions. It allows for early detection of changes that may require prompt intervention.
D. Encourage the client to consume at least 2 L of fluid daily.
In the oliguric phase of AKI, fluid intake is often restricted to prevent fluid overload. Encouraging excessive fluid intake may contribute to fluid retention and worsen the oliguria. Fluid management is carefully regulated based on the individual client's needs and renal function.
Correct Answer is C
Explanation
A. Stomatitis
Stomatitis refers to inflammation of the oral mucosa, which includes the lips, cheeks, gums, tongue, and palate. It can be caused by various factors, such as infections, irritants, or systemic conditions. While stomatitis may contribute to changes in oral odor, it encompasses a broader range of inflammatory conditions within the oral cavity.
B. Gingivitis
Gingivitis is inflammation of the gums (gingiva). It is often caused by plaque buildup and can lead to redness, swelling, and bleeding of the gums. While gingivitis may contribute to bad breath, it specifically involves inflammation of the gum tissue.
C. Halitosis
Halitosis refers to bad breath or a strong mouth odor. It can be caused by various factors, including poor oral hygiene, infections, dental conditions, or systemic diseases. In the context of a client with facial fractures, the nurse might observe halitosis due to challenges in maintaining oral hygiene or potential injuries.
D. Pyorrhea
Pyorrhea is an outdated term that was historically used to describe advanced stages of periodontal disease, including inflammation of the gums and supporting structures. The term is not commonly used in modern dental or medical terminology.
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