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 B
Explanation
A. Pinpoint pupils: Pinpoint pupils may indicate opioid use or a brainstem injury but are not related to Babinski's sign.
B. Dorsiflexion of the great toe: This is the characteristic response for a positive Babinski sign, which occurs when the toes fan out and the big toe dorsiflexes (moves upward) when the sole of the foot is stroked. It indicates an abnormal response and potential upper motor neuron damage.
C. Jerking contractions of the head and neck: This is indicative of a seizure activity, not Babinski's sign.
D. Pronation of the arms: This could be indicative of decerebrate posturing, not Babinski's sign.
Correct Answer is B
Explanation
A. While electrical cords along the walls may present a tripping hazard, they are not as significant a safety concern as scatter rugs, which can cause falls.
B. Scatter rugs are a significant safety risk, especially for clients with decreased vision, as they can easily cause tripping or slipping accidents. The nurse should recommend removing these rugs to prevent falls.
C. Handrails in the bathroom provide essential support and are considered a safety feature, not a risk.
D. Using a microwave for cooking is a safe practice, especially for individuals with limited vision, as it reduces the need for handling hot surfaces and cooking equipment.
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