A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?
Abdomen
Shoulder
Stomach
Neck
None
None
The Correct Answer is B
Choice A rationale: Testing skin turgor on the abdomen is common in infants and young children, but in older adults, abdominal skin often loses elasticity due to aging, making it an unreliable site for assessment.
Choice B rationale: The skin over the sternum or the subclavicular area (shoulder/chest) is the most reliable site for older adults. These areas typically maintain more elastic tissue, providing a more accurate reflection of hydration.
Choice C rationale: Assessing the stomach is essentially the same as the abdomen. This site is prone to skin sagging and loss of subcutaneous fat in elderly patients, which can lead to false-positive signs of dehydration.
Choice D rationale: The skin on the neck is thin and highly susceptible to wrinkles and sun damage. Lifting the skin here in an older adult will often show "tenting" even if the patient is well-hydrated.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states.
Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.
Choice B is wrong because antitoxin is not used to treat Lyme disease.
Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.
Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the
bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.
Choice D is wrong because skin necrosis is not a common complication of Lyme disease.
Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.
Correct Answer is C
Explanation
The leader allows the group to discuss whatever they would like to regarding their medications.
This is because a laissez-faire leadership style is characterized by minimal guidance and direction from the leader, and maximum freedom and autonomy for the followers.
The leader does not impose any rules or expectations on the group, and lets them decide how to manage their own learning and behavior.
Choice A is wrong because having group members vote on what they would like to learn about during the session is an example of a democratic leadership style, not a laissez-faire one.
A democratic leader solicits input and feedback from the group, and makes decisions based on consensus and majority rule.
Choice B is wrong because lecturing about medication adverse effects to the group members is an example of an authoritarian leadership style, not a laissez-faire one.
An authoritarian leader dictates what the group should do and how they should do it, without considering their opinions or preferences.
Choice D is wrong because encouraging group members to remain silent until questions are called for is an example of a paternalistic leadership style, not a laissez-faire one.
A paternalistic leader treats the group as if they are incapable of making their own decisions, and assumes a protective and nurturing role over them.
Normal ranges for leadership styles are not applicable in this context, as different styles may be more or less effective depending on the situation and the goals of the group.
However, some general advantages and disadvantages of each style are:
- Laissez-faire: Advantages - fosters creativity, independence, and self-motivation; Disadvantages - may lead to chaos, confusion, and lack of accountability.
- Democratic: Advantages - promotes participation, collaboration, and satisfaction; Disadvantages - may be time-consuming, inefficient, and conflict-prone.
- Authoritarian: Advantages - provides clarity, direction, and control; Disadvantages - may cause resentment, resistance, and dependency.
- Paternalistic: Advantages - creates trust, loyalty, and commitment; Disadvantages - may inhibit growth, development, and empowerment.
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