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. “Increase your caloric intake by eating foods high in protein.”

This is the appropriate choice. Increasing caloric intake with high-protein foods can help meet nutritional needs for individuals with Crohn's Disease, especially if malabsorption is a concern.

B. “Include fresh fruits and vegetables at each meal.”

While fresh fruits and vegetables are generally healthy, they may exacerbate symptoms in some individuals with Crohn's Disease, especially during flare-ups. It may be advisable to choose cooked or processed fruits and vegetables to minimize irritation.

C. “Maintain your weight by eating high-fat foods.”

This statement is not advisable. High-fat foods can contribute to symptoms such as cramping and diarrhea in individuals with Crohn's Disease. A well-balanced diet with an appropriate mix of nutrients is generally recommended.

D. “Drink whole milk to ensure adequate calcium intake.”

This statement is not advisable without considering individual tolerance. Whole milk is high in fat and may be difficult to digest for some individuals with Crohn's Disease. Additionally, if lactose intolerance is present, it may worsen symptoms. Alternative sources of calcium may need to be considered.

A. Ensure the rope knots are away from the pulleys. B. Ensure the child’s feet are against the footboard. C. Apply antibiotic ointment to the pin sites daily. D. Reduce the child’s fluid intake.

Correct Answer is B

Explanation

A. Ensure the rope knots are away from the pulleys.

While ensuring that rope knots are away from the pulleys is a general principle in traction care to maintain proper functioning, it is not directly related to the specific positioning of the child's feet in Buck's traction.

B. Ensure the child’s feet are against the footboard.

This statement is correct. Ensuring that the child's feet are against the footboard helps maintain proper hip alignment and prevent complications such as contractures. It is an important aspect of care when managing Legg-Calve-Perthes disease in Buck's traction.

C. Apply antibiotic ointment to the pin sites daily.

This action is not applicable to Buck's traction. Buck's traction involves the use of a boot or splint, and it does not include pins or pin sites. The use of antibiotic ointment for pin sites is more relevant in the context of skeletal traction.

D. Reduce the child’s fluid intake.

There is no indication to reduce the child's fluid intake specifically in the context of Buck's traction. Adequate hydration is generally important for overall health, and fluid restriction is not a standard practice for managing Legg-Calve-Perthes disease in Buck's traction.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has Crohn’s Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck’s traction. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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