Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?
a. The client has dry, scaly skin on bilateral upper and lower extremities.
b. The client states that he gets up three or more times during the night to urinate.
c. The client states that he feels lightheaded when he gets out of bed or stands up.
d. The nurse observes tenting on the back of the hand when testing skin turgor.
C
Orthostatic or postural hypotension can be caused by or worsened by dehydration. The other statements are not as indicative of the severe degree of dehydration as dizziness on standing.
You might also like to view...
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?
a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.
The nurse explains to an older female that the reason for pain during intercourse is:
1. a result of the atrophy of the ovaries. 2. the reduction of hormones. 3. the decrease of vaginal secretions. 4. fibrosis in the ducts of the breasts.
A child will begin taking methylphenidate (Ritalin) for attention-deficit/hyperactivity disorder. Important baseline information about this patient will include:
a. results of an electrocardiogram (ECG). b. family history of psychosis. c. height and weight. d. renal function.
F.N. has ICP monitoring in place with an intraventricular catheter. Nursing interventions
while the catheter is in place include which of the following? Select all that apply. a. Continuously monitoring the ICP waveforms b. Using aseptic technique when setting up the device c. Maintaining a cerebral perfusion pressure of 60 mm Hg d. Leveling the transducer even with the foramen of Monroe e. Administering prophylactic antibiotic therapy f. Notifying the physician if the ICP is greater than 30 mm Hg