A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Skin tenting present

Low body temperature

Blood pressure 178/90 mm Hg

Jugular vein distention

Answer and Explanation

The Correct Answer is A

A.   Skin tenting, where the skin remains pinched after being pulled up, is a classic sign of dehydration due to a lack of adequate fluid in the tissues.
B.   Low body temperature is not typically associated with dehydration; instead, a fever or elevated temperature is more commonly seen with infection.
C.   High blood pressure (178/90 mm Hg) could indicate hypertension or another condition, but it is not a direct sign of dehydration.
D.   Jugular vein distention is more commonly associated with fluid overload, heart failure, or other circulatory issues, rather than dehydration.

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Correct Answer is D

Explanation

A. A GCS of 15 indicates full consciousness and alertness.
B. A GCS of 12 indicates moderate impairment of consciousness.
C. A GCS of 6 indicates severe impairment, but not necessarily comatose.
D. A GCS of 8 or below is considered to indicate a comatose state.

A. Scale B. Pustule C. Macule D. Papule

Correct Answer is B

Explanation

A. Scale refers to flakes of dead skin cells and is not typically used to describe acne lesions.
B. Pustules are small, inflamed, pus-filled lesions, which are characteristic of acne.

C. A macule is a flat, discolored spot on the skin and does not apply to the raised, pus-filled lesions seen in acne.
D. A papule is a small, solid, raised lesion, but it is not filled with pus like a pustule. Acne lesions are often described as pustules when they contain pus.

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A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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