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 B

Explanation

A. Limit potassium-rich foods in the diet.

Limiting potassium is not a typical dietary modification for Cushing's disease. Potassium levels are usually affected in conditions such as Addison's disease, where there is a deficiency of cortisol. In Cushing's disease, the focus is more on sodium balance.

B. Decrease sodium intake.

This is the correct choice. Decreasing sodium intake is a dietary modification relevant to individuals with Cushing's disease. Excessive cortisol production can lead to sodium and water retention, and reducing sodium intake helps manage fluid balance.

C. Increase calorie intake.

While weight gain is a common symptom in individuals with Cushing's disease, simply increasing calorie intake may not be the most specific or appropriate dietary modification. Attention to overall dietary balance and specific components like sodium is more relevant.

D. Consume more calories from carbohydrates than protein.

The macronutrient composition of the diet (carbohydrates vs. protein) is not a specific consideration for individuals with Cushing's disease. The focus is more on overall dietary balance and addressing sodium intake.

A. Set the pad’s temperature to 42.2° C (108 F) B. Stop the treatment if the client’s skin becomes red. C. Leave the pad in place for at least 40 min. D. Use safety pins to keep the pad in place.

Correct Answer is B

Explanation

A. Set the pad’s temperature to 42.2° C (108 F).

The specific temperature setting for a heat application should be based on the healthcare provider's prescription and the therapeutic goals. The temperature should be within a safe and therapeutic range.

B. Stop the treatment if the client’s skin becomes red.

This is the correct choice. Redness on the skin during heat application may indicate potential skin irritation or the onset of a burn. Stopping the treatment if redness occurs is crucial to prevent further injury.

C. Leave the pad in place for at least 40 min.

The duration of heat application should also be based on the healthcare provider's prescription and therapeutic goals. Leaving the pad in place for a specific duration is important, but the exact time would depend on the therapeutic plan.

D. Use safety pins to keep the pad in place.

Safety pins should not be used to secure heat applications, as they can pose a risk of injury. Instead, healthcare professionals should use the appropriate securing devices provided with the heat application or follow facility protocols.

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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

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