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Multiple Choice
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?
A
Monitor the client's deep tendon reflexes
B
Check the client's skin turgor and mucous membranes
C
Assess the client's pupillary response to light
D
Measure the client's blood glucose level
Verified step by step guidance
1
Understand the concept of dehydration: Dehydration occurs when the body loses more fluids than it takes in, leading to a deficit in water and electrolytes. Common signs include dry mucous membranes, poor skin turgor, and decreased urine output.
Identify the most relevant assessment methods for dehydration: Skin turgor and mucous membranes are key indicators of hydration status. Skin turgor refers to the elasticity of the skin, which decreases in dehydration, while mucous membranes (e.g., inside the mouth) may appear dry.
Eliminate irrelevant options: Deep tendon reflexes, pupillary response to light, and blood glucose levels are not directly related to assessing hydration status. These tests are used for other conditions, such as neurological function or diabetes management.
Focus on the correct assessment techniques: To check skin turgor, gently pinch the skin on the back of the hand or forearm and observe how quickly it returns to its normal position. To assess mucous membranes, inspect the inside of the mouth for dryness or stickiness.
Apply the findings: If the skin turgor is slow to return or the mucous membranes are dry, these are signs of dehydration. The nurse should document these findings and consider further interventions, such as fluid replacement therapy.