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. Reposition the client every 2 hr: This is an essential action to prevent pressure ulcers and skin breakdown, especially for bedridden patients. Frequent repositioning helps alleviate pressure on bony prominences.
B. Assess the client's skin for increased coolness: While assessing skin temperature is important, it is not as immediate as repositioning the patient. Increased coolness may suggest poor circulation.
C. Keep the client's skin moist: Keeping the skin moist can lead to skin breakdown and increases the risk for pressure ulcers. Dry skin is typically preferred to avoid moisture-related damage.
D. Massage the client's red bony prominences: Massaging reddened skin can actually damage the tissue and worsen pressure injuries. It is advised to avoid massaging bony prominences that show signs of pressure.
Correct Answer is B
Explanation
A. Intact skin with localized erythema: This describes a stage 1 pressure injury.
B. Partial-thickness skin loss with red tissue in wound bed: This is characteristic of stage 2 pressure injuries, where there is damage to the epidermis and partial dermis.
C. Full thickness skin loss with visible adipose tissue: This describes a stage 3 pressure injury.
D. Full thickness skin loss with visible bone: This describes a stage 4 pressure injury.
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