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.)
Pale yellow urine
Poor skin turgor
Hypotension
Flat neck veins
Bradycardia
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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Correct Answer is D
Explanation
A. Linea nigra is not typically found in older adults.
B. Infants and children do not generally exhibit linea nigra.
C. Adolescents do not commonly have linea nigra.
D. Linea nigra is a dark line that appears on the abdomen of pregnant women due to hormonal changes and increased pigmentation.
Correct Answer is B
Explanation
A. Observing for facial symmetry assesses cranial nerves VII (facial nerve), not cranial nerve III.
B. Cranial nerve III (oculomotor nerve) is responsible for eye movement and pupillary response, making checking the pupillary response to light the correct action.
C. Testing visual acuity primarily assesses cranial nerve II (optic nerve), not cranial nerve III.
D. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.