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.
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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Related Questions
Correct Answer is D
Explanation
Diminished breath sounds in a client admitted with pneumonia. This is because diminished breath sounds indicate a worsening of the respiratory condition and a possible complication of pneumonia, such as atelectasis or pleural effusion.
The healthcare provider should be notified immediately to assess the client and order appropriate interventions.
Choice A is wrong because a report of joint pain by a client who recently started taking arthritis medication is not an urgent finding.
Joint pain is a common symptom of arthritis and may take some time to improve with medication.
The nurse should monitor the client’s pain level and administer analgesics as prescribed.
Choice B is wrong because report of decreased appetite and difficulty sleeping is not an immediate concern.
These are nonspecific symptoms that may be related to stress, anxiety, depression, or other factors.
The nurse should explore the possible causes of these symptoms and provide emotional support and education to the client.
Choice C is wrong because a weight loss of two pounds in a client admitted to congestive heart failure is not a critical finding.
Weight loss may indicate a reduction of fluid retention, which is a desired outcome for clients with heart failure.
The nurse should monitor the client’s weight daily and report any significant changes to the health care provider.
Normal ranges for weight, appetite, sleep, joint pain, and breath sounds vary depending on the individual’s age, gender, height, activity level, medical history, and other factors.
Correct Answer is B
Explanation
Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.
Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.
Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.
Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.
Choice A is wrong because relationship and evaluation are not techniques of physical assessment.
Relationship refers to the rapport and trust established between the nurse and the patient.
Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.
Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.
They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.
Choice D is wrong because color is not a technique of physical assessment.
Color is an aspect of inspection, which is one of the techniques of physical assessment.
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