A nurse is assessing an older adult client who is disoriented to time and place. The nurse notes that the client's eyes are sunken, the mouth is coated, the tongue has an extra longitudinal furrow, and the client's lips are cracked. The client's hand vein filling takes more than 5 seconds; tenting is apparent over the sternum; and the vital signs are BP 110/60 mm Hg, pulse 62, and respiratory rate of 12. Based on these assessment findings, which fluid or electrolyte imbalance should the nurse suspect?

Question

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The client's symptoms suggest fluid volume deficit, also known as dehydration. Sunken eyes, coated mouth, cracked lips, and a furrowed tongue are signs of dehydration. Poor skin turgor, as evidenced by tenting over the sternum and delayed hand vein filling, are also signs of dehydration. The client's vital signs are within normal limits for an older adult, but reflect compensatory mechanisms to maintain blood pressure and circulation. There are no other symptoms to suggest sodium excess or magnesium deficit.

A Nurse Is Assessing an Older Adult Client Who Is