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 B

Explanation

A. Check the client's visual acuity using a Snellen chart: This assesses cranial nerve II (optic), not cranial nerve VII.
B. Observe for facial symmetry while the client smiles: This is the correct method to assess cranial nerve VII (facial nerve), which controls facial muscles, including those responsible for smiling.
C. Have the client identify specific smells: This tests cranial nerve I (olfactory), not cranial nerve VII.

D. Whisper in one of the client's ears while occluding the other: This assesses cranial nerve VIII (vestibulocochlear), not cranial nerve VII.

A. Nodule B. Papule C. Wheal D. Macule

Correct Answer is D

Explanation

A. A nodule is a solid, raised lesion that is typically larger than 1 cm in diameter and extends deeper into the skin.
B. A papule is a small, raised, solid lesion, less than 1 cm, but not typically used for documenting freckles.
C. A wheal is a raised, erythematous area, often a result of an allergic reaction, not a freckle.
D. A macule is a flat, pigmented area of skin, less than 1 cm in diameter, which accurately describes freckles.

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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

Explanation

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Correct Answer is D

Explanation

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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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