Question

The nurse is performing an assessment on a client who has had nothing by mouth since the previous evening. Which manifestation related to the client's fluid restriction would be of concern to the nurse?

1) Edema
2) Increased hematocrit
3) Tenting skin
4) Dry mucous membranes
5) Increased blood pressure

Answer 1

Tenting skin and dry mucous membranes are of concern for a client under fluid restriction since these symptoms are indicative of dehydration. Increased hematocrit can also be a concern, reflecting hemoconcentration due to decreased plasma volume.

Step-by-step explanation:

The student asked which manifestation related to the client's fluid restriction would be of concern to the nurse, given that the client has had nothing by mouth since the previous evening. When a client has a fluid restriction and is showing signs of dehydration, certain clinical manifestations can be of particular concern. Of the options provided, tenting skin and dry mucous membranes are typical indicators of dehydration. Tenting skin occurs when the skin, once pinched and lifted, does not quickly return to its normal position and signifies a loss of skin turgor due to fluid depletion. Similarly, dry mucous membranes can indicate inadequate fluid intake or increased fluid loss. Increased hematocrit can also be a concern as it may indicate hemoconcentration due to decreased plasma volume. While edema and increased blood pressure are typically associated with fluid overload rather than restriction, they could indicate other health issues.