When assessing an older adult client, which finding is most indicative of dehydration?
Tenting noted in subclavicular area.
Loss of skin elasticity in the hand.
Skin is warm and dry.
Thinning hair in the lower extremities.
The Correct Answer is A
A. Skin tenting is a sign of dehydration. It occurs when the skin, after being pinched, does not quickly return to its normal position. This is often seen in areas with loose skin such as the subclavicular region.
B. Loss of skin elasticity is a normal aging process and not specifically indicative of dehydration. It can be seen in older adults regardless of hydration status.
C. Warm and dry skin can be a sign of dehydration. Dehydration leads to reduced sweating, which can result in dry skin, and it may also increase the body temperature, making the skin feel warm.
D. Thinning hair, especially in the lower extremities, is typically associated with circulatory issues or aging. It is not a direct sign of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This is not specific for egophony. While lung auscultation is part of a thorough assessment, egophony is assessed when the patient vocalizes a specific sound, not just breathing in and out.
B. This is a technique used to assess for whispered pectoriloquy, not egophony. The nurse would be looking for clarity of the whispered words, which is different from assessing for egophony.
C. This test is used to assess for bronchophony, where the nurse listens for clarity or increased volume of spoken words over the lungs. It is not related to egophony, which is a change in the sound when the client says "E."
D. This is the correct method for assessing egophony. In this test, the client is asked to say "E," and the nurse listens for any change in the sound. Normally, the "E" should sound like "E." If it sounds like "A," it indicates egophony, which can suggest a lung consolidation, such as might occur with a lung abscess.
Correct Answer is ["A","C"]
Explanation
WRIST - ABLE TO BEND WRIST BACK TOWARD FOREARM:
Abduction
Abduction refers to the movement of a body part away from the body's midline. This movement is typically used for fingers, arms, or legs, but not for the wrist. Therefore, this choice is incorrect for the wrist's range of motion.
Flexion
Flexion refers to the bending of a joint that reduces the angle between two body parts. For the wrist, flexion would involve bending the wrist forward, toward the palm of the hand. Since the patient is able to bend the wrist backward (toward the forearm), this is not the correct choice.
Extension
Extension refers to straightening a joint, which increases the angle between the body parts. For the wrist, extension is the movement where the hand moves away from the palm (backward toward the forearm). This is the correct choice because the patient is able to bend the wrist back toward the forearm, which is extension.
Adduction
Adduction refers to the movement of a body part toward the body's midline. This is not relevant to the wrist, so it is an incorrect option.
SHOULDER - UNABLE TO MOVE THE ARM AWAY FROM THE BODY:
Extension
Extension refers to the movement that straightens a joint, increasing the angle between two parts of the body. For the shoulder, this would involve moving the arm behind the body, and it's not the movement of the arm away from the body, so this is not the correct choice.
Adduction
Adduction refers to moving a body part toward the midline of the body. For the shoulder, this would involve moving the arm closer to the body. This does not correspond to the action of moving the arm away from the body, so this is not the correct choice either.
Flexion
Flexion refers to the bending of a joint that decreases the angle between two body parts. For the shoulder, this would involve raising the arm forward, not moving it away from the body. This is not the correct choice for the described movement.
Abduction
Abduction refers to the movement of a body part away from the midline of the body. In this case, the shoulder movement of moving the arm away from the body is abduction. Since the client is unable to move the arm away from the body (i.e., is experiencing weakness or limited ROM), the shoulder’s range of motion has a restriction in abduction.
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