A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

Choice A reason:

"This test will be repeated when your baby is 2 months old. “This is a false statement. Newborn genetic screening is usually performed shortly after birth. The test is not typically repeated when the baby is 2 months old, as it is meant to detect conditions early on, allowing for prompt intervention and management if necessary.

Choice B reason:

"Your baby will be given 2 ounces of water to drink prior to the test."This is a false statement. The baby does not need to drink water before the newborn genetic screening test. The test is usually performed by collecting a small blood sample from the baby's heel, and there is no need for the baby to drink water beforehand.

Choice C reason:

"This test should be performed after your baby is 24 hours old. “This is the appropriate statement. The nurse should include the statement that newborn genetic screening should be performed after the baby is 24 hours old. Newborn genetic screening, also known as newborn screening or heel prick test, is a standard test performed on newborns to detect certain genetic, metabolic, and congenital disorders early on. The test is typically done by pricking the baby's heel to collect a small sample of blood, which is then analysed in a laboratory.

Choice D reason:

"A nurse will draw blood from your baby's inner elbow. “This is a false statement. The correct location for collecting the blood sample for newborn genetic screening is the baby's heel. The nurse will prick the baby's heel to obtain a few drops of blood, which will then be collected on a special filter paper for laboratory analysis.

A:Provide frequent rest periods for the client. This is correct because the client has anaemia (low haemoglobin and hematocrit), which can cause weakness and fatigue. Rest periods can help conserve energy and prevent complications.
B:Instruct the client to avoid blowing their nose forcefully. This is correct because the client has thrombocytopenia (low platelet count), which can increase the risk of bleeding. Blowing the nose forcefully can cause nasal bleeding or rupture of blood vessels.
C: Assess the client’s level of orientation. This is correct because the client has hepatic encephalopathy (brain dysfunction due to liver failure), which can cause confusion, mood changes, and disorientation. Assessing the client’s level of orientation can help monitor the severity of hepatic encephalopathy and guide appropriate interventions.
D:Place the client on a low-carbohydrate diet. This is incorrect because a low-carbohydrate diet can worsen hepatic encephalopathy by increasing ammonia production in the gut. The client should be on a high-protein, high-calorie diet to provide adequate nutrition and prevent muscle wasting.
E: Restrict the client’s sodium intake. This is correct because the client has ascites (fluid accumulation in the abdomen) due to portal hypertension (high blood pressure in the portal vein). Restricting sodium intake can help reduce fluid retention and prevent further complications.
F Advise the client to avoid the use of soap and alcohol-based lotions. This is correct because the client has pruritus (itching) due to high bilirubin levels in the blood. Soap and alcohol-based lotions can dry out the skin and worsen pruritus. The client should use mild cleansers and moisturizers to soothe the skin.
G: Place the client under contact isolation. This is incorrect because there is no indication that the client has an infectious disease that requires contact isolation. Contact isolation is used for clients who have diseases that can be transmitted by direct or indirect contact with the client or their environment, such as Clostridioides difficile infection or methicillin-resistant Staphylococcus aureus infection.