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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 C

Explanation

A. This description relates more to a sensory discrimination test, not graphesthesia.

B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.

C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.

D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.

Correct Answer is C

Explanation

A. This is a dark vertical line that can appear on the abdomen during pregnancy, typically extending from the pubic area to the navel, which is not what is depicted in the image of a Mongolian Spot.

B. A chronic skin condition that results in red, itchy, scaly patches; this does not match the appearance of a Mongolian Spot.

C. This is the correct answer as it refers to a blue-gray pigmentation commonly found on the backs and buttocks of infants, particularly in individuals of Asian or African descent.

D. These are small, white cysts that can appear on the skin, typically on the face, and are not consistent with the description of a Mongolian Spot.

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