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A nurse is assessing a client who reports taking a medication that causes increased urination resulting in dehydration for the past 3 days. Which findings should the nurse expect in a client who is dehydrated? (Select all that apply.)

A.

Pale yellow urine

B.

Poor skin turgor

C.

Hypotension

D.

Flat neck veins

E.

Bradycardia

Question Solution

Correct Answer : B,C,D

A. Pale yellow urine is typically associated with good hydration; dehydration would likely result in darker urine.  

 

B. Poor skin turgor is a classic sign of dehydration, indicating a lack of adequate fluid in the tissues.  

 

C. Hypotension (low blood pressure) can occur with dehydration due to decreased blood volume.  

 

D. Flat neck veins may indicate a decrease in venous return due to low blood volume associated with dehydration.  

 

E. Bradycardia (slow heart rate) is not typically a finding associated with dehydration; instead, dehydration often leads to tachycardia (increased heart rate) as the body attempts to compensate for low blood volume.  


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View Related questions

Correct Answer is D

Explanation

A. The iliac pulse is located near the pelvis and is not used for assessing circulation in the lower extremities.


B. The femoral pulse is located in the upper thigh, not near the posterior tibial area.


C. The popliteal pulse is found at the back of the knee and is higher than the posterior tibial location.


D. The posterior tibial pulse is correctly located behind the medial malleolus on the inner side of the ankle. This location is where the posterior tibial artery is accessible and is commonly used to assess blood flow to the lower extremities.

Correct Answer is D

Explanation

A. Checking pupillary response to light assesses cranial nerve II (optic nerve).

B. Observing for facial symmetry primarily assesses cranial nerves VII (facial nerve) and possibly V (trigeminal nerve).

C. Testing for sense of smell assesses cranial nerve I (olfactory nerve).

D. Eliciting the gag reflex assesses cranial nerve IX (glossopharyngeal nerve) and also cranial nerve X (vagus nerve), making it the correct action to assess cranial nerve IX.

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