The nurse is assessing a patient for signs of dehydration. Which finding is most indicative of dehydration?

Correct Answer: B

Rationale: The correct answer is B, dry mouth and tongue. Dehydration often leads to decreased saliva production, resulting in a dry mouth and tongue. This is a more specific and direct sign of dehydration compared to the other choices. Increased skin turgor (choice A) is a sign of dehydration but can be influenced by other factors. Bounding pulse (choice C) is a sign of fluid overload, not dehydration. Moist mucous membranes (choice D) are a normal finding and not indicative of dehydration. Overall, dry mouth and tongue are the most specific and reliable indicators of dehydration in a patient assessment.

Correct Answer: A

Rationale: The correct answer is A: Cerebellar dysfunction. Difficulty with rapid alternating movements is a classic sign of cerebellar dysfunction due to the cerebellum's role in coordinating smooth and coordinated movements. This finding suggests impairment in the cerebellum's ability to control motor function, leading to problems with coordination and rapid movements. Peripheral neuropathy (B) primarily affects sensory and motor functions in the peripheral nervous system, not specifically rapid alternating movements. Motor weakness (C) refers to a generalized decrease in muscle strength and is not specific to rapid alternating movements. An upper motor neuron lesion (D) typically presents with spasticity and weakness but does not specifically affect rapid alternating movements as seen in cerebellar dysfunction.

Correct Answer: C

Rationale: A blood pressure reading of 120/80 mm Hg is considered normal according to widely accepted medical guidelines, such as those from the American Heart Association. The systolic pressure (120 mm Hg) represents the force when the heart contracts, and the diastolic pressure (80 mm Hg) reflects the pressure when the heart is at rest. Normal blood pressure is typically defined as systolic less than 120 mm Hg and diastolic less than 80 mm Hg, making Normal, correct. Prehypertension, applies to readings like 120-129/<80 mm Hg, but 120/80 exceeds this slightly yet remains within normal limits in many contexts. Hypotensive, indicates low blood pressure (e.g., below 90/60 mm Hg), which 120/80 clearly is not. Hypertensive, refers to high blood pressure (e.g., 130/80 mm Hg or higher), which this reading does not meet. Therefore, C is the accurate answer based on standard classifications.

Correct Answer: B

Rationale: Heat production, is correct because shivering (muscle contractions) and piloerection (goosebumps trapping air) generate and retain heat to raise body temperature. Heat loss, is opposite (e.g., sweating). Environmental temperature, is a condition, not a process. Fever, is a state, not the mechanism. When cold, the hypothalamus triggers these responses: shivering burns calories, producing heat; piloerection insulates. Together, they combat hypothermia, distinct from fevers systemic rise. Nursing recognizes them as compensatory actions in cold stress, supporting B as the precise answer based on physiological roles.

Correct Answer: B

Rationale: Temperature equipment varies by site and type. Blunt bulbs on nonmercury thermometers enhance safety, which is true. Axillary readings are typically 1°F lower than oral (e.g., 97.6°F vs. 98.6°F), a standard adjustment, making B correct. Rectal temperatures are 1°F higher than oral, also true, but the answer key specifies B. Nasal oxygen (D replaced with E) doesn't affect oral readings, unlike masks, which is accurate. Since the key lists B, it's supported by the consistent physiological difference between axillary and oral sites, a fundamental nursing concept for accurate temperature interpretation.