The nurse is performing routine assessments on five hospitalized clients. Which of the following clients does the nurse expect to exhibit poor skin turgor? Standard Text: Select all that apply
1. The client had an open appendectomy 2 days ago.
2. The client was admitted with severe nausea and vomiting.
3. The client has lost 16 pounds during the last 30 days.
4. The client has had a high fever during the last four days and was admitted through the Emergency Department last night.
5. The client was admitted this morning with a severe migraine.
2,3,4
Rationale 1: The client had an open appendectomy 2 days ago. The client who had an open appendectomy will most likely be prepared for discharge at this time. It is unlikely that this client will exhibit poor skin turgor at this time.
Rationale 2: The client was admitted with severe nausea and vomiting. The client who was admitted with severe nausea and vomiting will most likely exhibit signs associated with dehydration. Poor skin turgor is associated with dehydration.
Rationale 3: The client has lost 16 pounds during the last 30 days. The client who has lost a large amount of weight will often exhibit poor skin turgor.
Rationale 4: The client has had a high fever during the last four days and was admitted through the Emergency Department last night. The client who has had a high fever will often exhibit poor skin turgor due to dehydration.
Rationale 5: The client was admitted this morning with a severe migraine. The client who has a severe migraine will not necessarily demonstrate signs of dehydration.
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