The nurse is assessing the hydration status of the patient. Which ...

[TFauchery]

The nurse is assessing the hydration status of the patient. Which action(s) demonstrates knowledge of proper assessment? (Select all that apply.)
 
  a. Monitoring the patient's daily weight.
  b. Assessing the patient's skin turgor on the back of the hand.
  c. Checking the patient's blood glucose level four times a day.
  d. Assessing for skin tenting on the patient's forehead.
  e. Asking the patient if he is experiencing thirst.

Question 2

The nurse uses a visual aid to demonstrate how a coup-contrecoup injures the brain. Which information should the nurse include? (Select all that apply.)
 
  a. These injuries allow the brain to twist on the brainstem.
  b. These injuries cause the brain to move forward to strike the anterior interior skull.
  c. These injuries allow the brain to compress on itself.
  d. These injuries cause the brain to strike the bony area opposite of the site of impact.
  e. These injuries cause the brain to lose small amounts of cerebrospinal fluid.

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Answer to Question 1

A, D, E
The skin of the abdomen, forearm, sternum, forehead, and thigh can be tented as a test for skin turgor by gently pinching up a fold of skin and observing the delay in return to normal. Assess-ment of skin turgor is not reliable on the back of the hand. Weight and experiencing thirst can be indicators of hydration status, along with further assessment. The patient's blood glucose level is not an assessment parameter for hydration status.

Answer to Question 2

B, D
In a coup-contrecoup injury, the brain moves forward, striking the anterior interior wall of the cranium, and moves back, striking the bony area opposite the site of the impact, causing two areas of injury.