Question

An older adult patient is admitted to the hospital with dehydration resulting from prolonged vomiting. Which assessment finding by the nurse is most consistent with severe dehydration?

a. The skin color over the nose and ears has a blue tint.
b. The skin of the extremities is warm and dry to touch.
c. Pressing the skin over the ankles causes pitting for 10 seconds.
d. Pinching the skin under the clavicle causes tenting for 10 seconds.

Answer 1

The assessment finding most consistent with severe dehydration due to prolonged vomiting in an older adult patient is 'd. Pinching the skin under the clavicle causes tenting for 10 seconds,' which indicates a loss of skin turgor, a common sign of significant fluid loss.

Step-by-step explanation:

The most consistent assessment finding by the nurse that is indicative of severe dehydration in an older adult patient suffering from prolonged vomiting is d. Pinching the skin under the clavicle causes tenting for 10 seconds. Skin tenting occurs when the skin is pinched and lifted but does not promptly return to its original position. This sign reflects a loss of skin turgor, which is a hallmark of dehydration resulting from significant fluid loss. When a patient exhibits severe dehydration, other symptoms may include a rapid heart rate, a decrease in blood pressure, dizziness, confusion, fatigue, and reduced urine output. Immediate treatment is essential to replenish fluids and electrolytes in the body and prevent further complications.