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Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?*1 pointa. The client has dry, scaly skin on bilateral upper and lower extremities.b. The client states that he gets up three or more times during the night to urinate.c. The client states that he feels lightheaded when he gets out of bed or stands up.d. The nurse observes tenting on the back of the hand when testing skin turgor.

Question

Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?*1 pointa. The client has dry, scaly skin on bilateral upper and lower extremities.b. The client states that he gets up three or more times during the night to urinate.c. The client states that he feels lightheaded when he gets out of bed or stands up.d. The nurse observes tenting on the back of the hand when testing skin turgor.

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Solution

The answer is "d. The nurse observes tenting on the back of the hand when testing skin turgor."

Here's why:

a. Dry, scaly skin can be a sign of many conditions, including eczema, psoriasis, or other skin conditions. It's not a definitive sign of dehydration.

b. Getting up three or more times during the night to urinate could be a sign of a urinary tract infection, prostate problems in men, or diabetes. It's not necessarily a sign of dehydration.

c. Feeling lightheaded when getting out of bed or standing up could be a sign of orthostatic hypotension, a condition in which blood pressure falls significantly when a person stands up quickly. While this can be caused by dehydration, it's not the most specific sign.

d. Tenting of the skin, however, is a classic sign of dehydration. When the skin is pinched and it doesn't snap back quickly, this is called "tenting," and it's often used as a quick test for dehydration. This is because when the body is dehydrated, it lacks enough fluid to keep the skin plump and resilient.

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