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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I will call for pain medication before the previous dose wears off.”
The statement "I will call for pain medication before the previous dose wears off" indicates an understanding of proactive pain management. In postoperative pain control, it is generally more effective to stay ahead of the pain by taking pain medication on a scheduled basis rather than waiting until the pain becomes severe. This approach helps to maintain a more consistent level of pain relief.
B. “I will call for pain medication as my pain becomes intolerable.”
Waiting until the pain becomes intolerable may result in suboptimal pain control. It's more effective to take pain medication before reaching a point of intolerable pain.
C. “I will wait for you to evaluate my pain before asking for more.”
Waiting for the nurse to evaluate pain before requesting more medication may result in delays in pain relief. Pain management often involves collaboration between healthcare providers and patients, and timely communication about pain levels is essential.
D. “I will ask for less medication to avoid addiction.”
This statement reflects a concern about addiction but may lead to inadequate pain relief. Pain management should prioritize effective pain control while balancing the risks and benefits of medications. The goal is to provide sufficient pain relief without compromising the client's well-being.
Correct Answer is D
Explanation
A. Drink carbonated beverages.
Carbonated beverages may cause bloating and gas, which can be uncomfortable for individuals with COPD. It's generally advisable to choose non-carbonated and non-caffeinated beverages.
B. Decrease fiber intake.
Decreasing fiber intake is not a recommended approach for individuals with COPD. Fiber is important for digestive health and overall well-being. A balanced diet, including adequate fiber, is generally encouraged.
C. Use bronchodilators after meals.
The timing of bronchodilator use is typically based on a schedule or as needed for symptom control, rather than being specifically linked to mealtime. It's important to follow the healthcare provider's instructions regarding the use of bronchodilators.
D. Increase protein intake.
Increasing protein intake is an appropriate nutritional recommendation for individuals with COPD. Protein is important for maintaining respiratory muscle strength and overall health.
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