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 C

Explanation

A. 5th Intercostal Space, Midclavicular Line. This is the location for the apical pulse (PMI) at the mitral area, not the aortic valve.

B. 2nd Intercostal Space, Left Sternal Border. This is the location of the pulmonic valve, not the aortic valve.

C. 2nd Intercostal Space, Right Sternal Border. The aortic valve is best auscultated at the right second intercostal space, next to the sternum.

D. 3rd Intercostal Space, Left Sternal Border. This is the Erb’s point, which provides equal S1 and S2 sounds, but it is not the best location for auscultating aortic valve dysfunction.

A. "Right now, I can't bathe or dress myself, but my family will help me." B. "I can always come stay in the hospital again if I don't want to take care of my own needs." C. "Taking care of myself is important, but it's okay if I don't want to do anything." D. "I will take my medicines as I should and know who to call if I have bad thoughts."

Correct Answer is D

Explanation

A. "Right now, I can't bathe or dress myself, but my family will help me." Dependence on family for basic self-care suggests the client is not yet independent enough for discharge.

B. "I can always come stay in the hospital again if I don't want to take care of my own needs." This statement shows a lack of commitment to self-care and reliance on hospitalization as a coping mechanism.

C. "Taking care of myself is important, but it's okay if I don't want to do anything." Readiness for discharge includes a commitment to self-care, and this statement suggests a lack of motivation.

D. "I will take my medicines as I should and know who to call if I have bad thoughts." This statement shows insight into the importance of medication adherence and knowledge of available support resources, indicating readiness for discharge.

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