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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pinnae of the ears are one of the most reliable sites for detecting cyanosis in individuals with dark skin, as the color changes are more apparent in the mucous membranes and earlobes.
B. Dorsal surface of the hand may not reliably show cyanosis in darker skin tones, and it’s often less
visible.
C. Dorsal surface of the foot is not typically where cyanosis would be identified.
D. Conjunctivae can be used for detection in individuals with darker skin, but it is typically harder to visualize than the pinna.
Correct Answer is ["A","B","D"]
Explanation
A. A lesion that is asymmetrical is concerning, as melanoma and other skin cancers tend to be irregular in shape. This is an important warning sign.
B. Red and black coloration in a lesion is concerning because it can indicate changes in blood flow or necrosis, both of which are suspicious for malignancy.
C. A flat lesion does not automatically indicate a problem, as many benign lesions, like moles, can be flat. The texture or elevation of the lesion is not always a concern unless there are other risk factors.
D. A lesion larger than 6 mm is concerning, especially if it is changing in size or shape. Larger lesions should be evaluated by a healthcare provider for potential malignancy.
E. Round edges are typically a characteristic of benign lesions, so this is not as concerning unless there are other warning signs present.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.