A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

Press the skin over the client's ankle bone.

Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen.

Lightly palpate the skin using the fingertips.

Grasp a fold of skin on the client's forearm or near the sternum.

Answer and Explanation

The Correct Answer is D

A. Press the skin over the client's ankle bone. Skin over the bony prominences is not ideal for assessing turgor, as it may not accurately reflect dehydration.

B. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. This describes petechiae, which is a sign of bleeding disorders, not hydration status.

C. Lightly palpate the skin using the fingertips. Palpation does not assess elasticity.

D. Grasp a fold of skin on the client's forearm or near the sternum. The best way to check for dehydration is by pinching the skin on the sternum or forearm and observing how quickly it returns to normal.

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Correct Answer is D

Explanation

A. Examine the back before the general inspection of the skin: Skin assessment should follow a general inspection.

B. Note dry, flaky skin as an expected finding: While common in older adults, it may indicate dehydration or dermatologic conditions.

C. Use a penlight to examine the back in greater detail: Penlights are typically used for darker areas (e.g., mouth, wounds), not flaky skin.

D. Pinch up a fold of skin to check for turgor: Assesses hydration status, which is important since dehydration contributes to dry, flaky skin.

A. The client takes a 20-min nap each afternoon. B. The client has gained 4.5 kg (10 lb) in the past month. C. The client takes a walk for 1 hr each day. D. The client is taking a poetry class.

Correct Answer is B

Explanation

A. The client takes a 20-min nap each afternoon. Taking a short nap is a healthy coping mechanism and does not indicate ineffective coping.

B. The client has gained 4.5 kg (10 lb) in the past month. Sudden weight gain can indicate emotional eating or stress-related metabolic changes, which are signs of ineffective coping.

C. The client takes a walk for 1 hr each day. Walking is a positive coping strategy that helps manage stress.

D. The client is taking a poetry class. Engaging in creative activities is a healthy coping mechanism that can reduce stress.

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A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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