The nurse is concerned that an older client exhibits lethargy and headache. What other assessments does the nurse perform immediately? Select all that apply.
1. Mental status
2. Orthostatic blood pressure
3. Daily weight
4. Long tongue furrows
5. Forearm tenting of the skin
1. Mental status
2. Orthostatic blood pressure
4. Long tongue furrows
Explanation: 1. Confusion is a symptom of dehydration in the older adult. While confusion does happen from other causes, this would be an excellent indicator in the presence of existing headache and lethargy.
2. An orthostatic blood pressure is an immediate indication of the client's cardiac output in the presence of dehydration and is an essential initial assessment.
3. Weight loss would occur in a client that is dehydrated. Weight gain is an indication of overhydration. However, weight loss can occur for other reasons and is not an immediate indicator of fluid status but an ongoing indicator.
4. Long tongue furrows are symptoms of dehydration in the older adult.
5. Tenting on the forearm is not an accurate indicator of dehydration because the older client will often have tenting with a normal hydration status as a result of loss of skin elasticity.
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