Question

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?

1. Skin turgor
2. Urine output
3. Weight
4. Mental status

Answer 1

The priority assessment for a client with dehydration is mental status. It provides immediate information about the effect of dehydration on brain function and can indicate the severity and acuteness of the condition.

Step-by-step explanation:

In addressing the question of priority assessment for a client with dehydration, the correct answer would be mental status. Dehydration can lead to significant consequences including cognitive impairment due to inadequate cerebral perfusion and the reduced ability for the brain to function properly. The effects of dehydration such as loss of weight and disturbances in acid-base balance can contribute to confusion and disorientation, making mental status assessment crucial for immediate understanding of the patient's condition and necessary interventions.

Other assessments like skin turgor, urine output, and weight are also important but are not the immediate priority. While weight change is a good indicator of the degree of dehydration, and both skin turgor and urine output can provide information about the body's hydration state, they do not assess the acute impact on brain function as directly as mental status evaluation does. The patient's confusion and complaint of thirst as well as their hypotension (a blood pressure of 70/45) are indicators of severe dehydration and possibly shock that require urgent attention.