Nokea
The nurse is assessing a client with suspected dehydration. Which of the following findings would support this diagnosis? Select all that apply.
- A. Sunken fontanelles in an infant.
- B. Tachycardia.
- C. Increased urine specific gravity.
- D. Dry skin.
- E. Hypotension.
Correct Answer: A, B, C, D, E
Rationale: Dehydration presents with sunken fontanelles, tachycardia, increased urine specific gravity, dry skin, and hypotension due to fluid loss.
You may also like to solve these questions
A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse:
- A. When desired because sterilization is immediate.
- B. As soon as scrotal edema and tenderness resolve.
- C. When the sperm count reflects sterilization.
- D. After 6 to 10 ejaculations.
Correct Answer: C
Rationale: A vasectomy requires confirmation of azoospermia (no sperm in semen) via sperm count before unprotected intercourse to ensure sterilization, as sperm may remain in the reproductive tract initially.
The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye?
- A. Iris.
- B. Cornea.
- C. Retina.
- D. Sclera.
Correct Answer: C
Rationale: Uncontrolled hypertension can cause retinopathy, damaging the retina, which should be assessed.
The physician has ordered a low-potassium diet for a client. Which of the following food choices indicates that the client needs further instruction regarding the diet?
- A. Apple.
- B. Baked potato.
- C. Carrots.
- D. Spinach.
Correct Answer: B
Rationale: Baked potatoes are high in potassium, so choosing them indicates a need for further teaching on a low-potassium diet.
The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?
- A. Hearing problems.
- B. Speech defect.
- C. Chronic sinus infections.
- D. Tonsillitis.
Correct Answer: A, B
Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.
When using crutches, the client should be instructed to bear weight primarily on the:
- A. Axillae
- B. Elbows
- C. Upper arms
- D. Hands
Correct Answer: D
Rationale: Weight should be borne on the hands when using crutches to prevent nerve damage from pressure on the axillae. Elbows and upper arms are not primary weight-bearing areas.