Distribution of Body Fluids
Distribution of Body Fluids ( 6 Questions)
A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect? (Select all that apply.)
Decreased skin turgor is a sign of dehydration because the skin loses elasticity when the body loses water. The nurse can assess this by pinching the skin on the back of the hand or the forehead and observing how quickly it returns to its normal position. If it takes longer than a few seconds, it indicates decreased skin turgor.
Increased heart rate is a sign of dehydration because the heart has to work harder to pump blood when the blood volume is low. The body also tries to compensate for the fluid loss by increasing the heart rate and constricting the blood vessels.
Crackles in the lungs are not a sign of dehydration, but rather a sign of fluid overload or pulmonary edema. Crackles are caused by fluid accumulation in the alveoli, which interferes with gas exchange and produces a crackling sound when breathing. This choice is incorrect.
Low urine output is a sign of dehydration because the kidneys try to conserve water by producing less urine. The urine also becomes more concentrated and darker in color when the body is dehydrated.
Dry mucous membranes are a sign of dehydration because the body loses moisture from the mouth, nose, and eyes when it is dehydrated. The nurse can assess this by looking at the lips, tongue, and oral cavity for dryness and cracking.
Choice A reason:
Decreased skin turgor is a sign of dehydration because the skin loses elasticity when the body loses water. The nurse can assess this by pinching the skin on the back of the hand or the forehead and observing how quickly it returns to its normal position. If it takes longer than a few seconds, it indicates decreased skin turgor.
Choice B reason:
Increased heart rate is a sign of dehydration because the heart has to work harder to pump blood when the blood volume is low. The body also tries to compensate for the fluid loss by increasing the heart rate and constricting the blood vessels.
Choice C reason:
Crackles in the lungs are not a sign of dehydration, but rather a sign of fluid overload or pulmonary edema. Crackles are caused by fluid accumulation in the alveoli, which interferes with gas exchange and produces a crackling sound when breathing. This choice is incorrect.
Choice D reason:
Low urine output is a sign of dehydration because the kidneys try to conserve water by producing less urine. The urine also becomes more concentrated and darker in color when the body is dehydrated.
Choice E reason:
Dry mucous membranes are a sign of dehydration because the body loses moisture from the mouth, nose, and eyes when it is dehydrated. The nurse can assess this by looking at the lips, tongue, and oral cavity for dryness and cracking.