The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

Inspection of lips and mucous membranes.

Pinches the skin on back of the hand.

Measures pulse and blood pressure.

Obtains client's daily weight.

Palpates scalp and hair distribution.

Answer and Explanation

Correct Answer : A,B,C,D

The correct answers are Choices A, B, C, and D.Choice A rationale: Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale: Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale: Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale: Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale: Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.

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Correct Answer is B

Explanation

Interview the client privately and ask if anyone is harming her.

This is because the nurse has a duty to assess the client for possible elder abuse and report any suspicions to the appropriate authorities.

The nurse should not assume that the son is the abuser or that the client will disclose the abuse without being asked directly.

The nurse should also respect the client’s autonomy and privacy and not confront the son or provide an elder abuse brochure without the client’s consent.

Choice A is wrong because it may imply that the client is responsible for preventing the abuse or that the nurse has already made a judgment about the situation.

It may also be ineffective if the client is unable or unwilling to read the brochure or seek help. Choice C is wrong because it may delay the assessment and intervention for the client.

It may also be biased and unfair to observe the son without interviewing him or the client first.

Choice D is wrong because it may violate the client’s rights and preferences.

It may also be premature to report the abuse without confirming it with the client or obtaining more evidence.

A. Enjoy a glass of wine before bed. B. Do not exercise at least one hour prior to sleep. C. Go to bed at the same time every evening. D. Read a book 30 minutes before bedtime. E. Do not take naps during the day.

Correct Answer is ["B","C","E"]

Explanation

These interventions are based on the principles of sleep hygiene and cognitive behavioral therapy for insomnia (CBT-I), which are evidence-based strategies to promote better sleep.

Choice A is wrong because alcohol can disrupt sleep quality and cause frequent awakenings during the night. It can also interfere with the normal sleep cycle and reduce REM sleep.

Choice D is wrong because reading a book 30 minutes before bedtime can be stimulating and make it harder to fall asleep. It can also violate the stimulus control therapy, which aims to associate the bed only with sleep and sex and avoid any other activities that may keep the mind alert.

Some additional sentences are:

Normal ranges for sleep vary depending on age, lifestyle, and individual factors, but generally adul,ts need about 7 to 9 hours of sleep per night.
Insomnia is a common sleep disorder that affects about 10% to 30% of adults and can have negative impacts on physical and mental health, as well as quality of life.
If insomnia persists despite following these interventions, it is advisable to consult a doctor or a sleep specialist for further evaluation and treatment options.

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The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

Nursing Test Bank

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Explanation

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Correct Answer is ["B","C","E"]

Explanation

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