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 A

Explanation

A. Assess risk for immediate harm should be the priority. The nurse needs to evaluate whether the client is in immediate danger and take the necessary steps to ensure their safety.
B. Instructing the client on how to leave the relationship is important, but the priority is to assess if the client is in immediate danger first.
C. Implementing a safety plan is essential, but first, the nurse must assess the immediate risks to the client's safety.
D. Referring the client to a community support group is a supportive action but should follow the priority steps of ensuring safety and assessing immediate harm.

A. Testing visual acuity B. Eliciting the gag reflex C. Observing for facial symmetry D. Checking the pupillary response to light

Correct Answer is D

Explanation

A. Testing visual acuity: This assesses cranial nerve II (optic), not cranial nerve III.
B. Eliciting the gag reflex: This assesses cranial nerve IX and X (glossopharyngeal and vagus), not cranial nerve III.
C. Observing for facial symmetry: This assesses cranial nerve VII (facial nerve), not cranial nerve III.
D. Checking the pupillary response to light: Cranial nerve III (oculomotor) is responsible for controlling pupil constriction in response to light, making this the correct method to assess cranial nerve III.

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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?

Nursing Test Bank

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