The nurse is performing an assessment on an elderly client admitted for altered mental status
After assessing the client's vital signs, the nurse notices which of the following signs that might indicate altered fluid balance? (Select all that apply.) 1. Dry oral mucosa
2. Lower extremity edema
3. Dark colored urine
4. Increased heart rate
5. Increased respiratory rate
1, 3, 4
Rationale: Elderly clients with an altered mental status are at risk for dehydration. When performing a physical assessment there are several signs that may indicate that the client has an altered fluid status including: dry oral mucosa, dark colored urine, and increased heart rate. Lower extremity edema is linked to excess fluid volume and increased respiratory rate is not affected by hydration status.
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