The nurse is performing a head-to-toe assessment on an older adult client who was admitted to the hospital with dehydration. Which of the following findings are consistent with this condition? Standard Text: Select all that apply
1. Tenting noted on dorsal aspect of client's hand when skin turgor was assessed.
2. Client has produced 175 milliliters over the last 8 hours.
3. Dentures are loose, small sores noted in oral mucosa.
4. Healthcare provider notes client exhibiting xerostomia.
5. Client's apical heart rate is 82 beats per minute.
2,3,4
Rationale 1: Tenting noted on dorsal aspect of client's hand when skin turgor was assessed. Tenting is not an appropriate way to monitor for dehydration in the older adult client due to loss of skin elasticity.
Rationale 2: Client has produced 175 milliliters over the last 8 hours. The client is not producing an adequate amount of urine, which may indicate the client is dehydrated. The client should have produced at least 240 milliliters over the last 8 hours.
Rationale 3: Dentures are loose, small sores noted in oral mucosa. The client with loosely fitting dentures and sores on the oral mucosa may be experiencing dehydration.
Rationale 4: Healthcare provider notes client exhibiting xerostomia. The client with xerostomia is not producing saliva and this can be associated with dehydration.
Rationale 5: Client's apical heart rate is 82 beats per minute. The client's heart rate is within normal limits and does not indicate that the client is dehydrated.
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