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. Xerostomia
Xerostomia is dry mouth, a condition where the salivary glands do not produce enough saliva. It can have various causes, including medications, medical conditions, or dehydration. Xerostomia is not directly related to teeth grinding.
B. Halitosis
Halitosis is bad breath. While dental issues, including bruxism (teeth grinding), can contribute to bad breath, halitosis itself does not specifically describe teeth grinding.
C. Bruxism
Bruxism is the medical term for teeth grinding or clenching, especially during sleep. If a client suspects or reports grinding their teeth at night, it is appropriate to document and discuss the issue as bruxism. Bruxism can lead to dental problems, jaw pain, and headaches.
D. Sordes
Sordes refers to a collection of foul matter, such as debris or crusted material, around the mouth. It is not related to teeth grinding.
Correct Answer is A
Explanation
A. Apply a cool, wet compress to the affected area.
This action can help soothe the affected skin and reduce inflammation associated with eczema. It is important to avoid hot water, as it can further dry out the skin.
B. Launder clothing with fabric softener.
Fabric softeners can contain chemicals that may irritate sensitive skin. It is advisable to use mild, fragrance-free detergents and skip fabric softeners.
C. Give bubble baths every day.
Bubble baths can be drying to the skin, and frequent bathing may exacerbate eczema. It is recommended to keep baths short, use lukewarm water, and avoid harsh soaps.
D. Use wool gloves in the wintertime.
Wool can be irritating to sensitive skin, and for individuals with eczema, it's better to use soft, breathable fabrics for gloves to minimize irritation.
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