A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit?
A.
Tenting
B.
Protruding eyeballs
C.
Elevated blood pressure
D.
Dry mucous membranes
The Correct Answer and Explanation is :
The correct answer is A. Tenting.
Explanation:
When evaluating an older adult client for dehydration, especially with a body mass index (BMI) of 17.5, the nurse should be vigilant for signs of fluid-volume deficit. Dehydration in older adults can be subtle and may present differently than in younger populations. The signs of dehydration can be divided into various categories including skin turgor, mucous membranes, blood pressure, and other systemic indicators.
- Tenting: Skin turgor refers to the skin’s elasticity and its ability to return to its normal position after being pinched. Tenting occurs when the skin remains elevated in a tent-like fashion after being pinched, indicating reduced elasticity due to fluid loss. In older adults, this is a classic sign of dehydration as their skin loses elasticity over time. Tenting is often assessed by pinching the skin on the back of the hand or the forearm. This is a reliable indicator of fluid-volume deficit.
- Protruding eyeballs: While protruding or sunken eyeballs can be a sign of severe dehydration, they are less commonly used in routine assessments. Protruding eyeballs are more likely associated with other conditions, such as thyroid disorders, rather than dehydration alone.
- Elevated blood pressure: In cases of fluid-volume deficit, elevated blood pressure is not typically observed. Instead, dehydration often leads to a decrease in blood pressure or orthostatic hypotension (a drop in blood pressure upon standing).
- Dry mucous membranes: Dry mucous membranes are also a sign of dehydration, particularly in the mouth and throat. This is another important indicator to assess, as dehydration leads to reduced fluid levels in the body, including the mucous membranes.
In summary, while both tenting and dry mucous membranes are important indicators of fluid-volume deficit, tenting is often considered a more direct and observable sign of dehydration in an older adult client. It is a physical assessment tool used to gauge skin elasticity and hydration status effectively.