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?

Examine the back before the general inspection of the skin.

Note dry, flaky skin as an expected finding.

Use a penlight to examine the back in greater detail.

Pinch up a fold of skin to check for turgor.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is D

Explanation

A. Apply cornstarch to keep the skin dry. Cornstarch can cause skin irritation or promote bacterial/fungal growth, which increases the risk of breakdown rather than preventing it.

B. Reposition the client every 3 hr. Clients at risk for skin breakdown should be repositioned at least every 2 hours to relieve pressure and prevent pressure ulcers.

C. Massage bony prominences to promote circulation. Massaging bony prominences can cause tissue damage and increase the risk of pressure ulcers instead of preventing them.

D. Provide the client with a diet high in protein. Protein is essential for skin repair and maintenance, helping prevent breakdown and promote healing.

A. Move body parts rapidly through the movements. B. Support extremities above and below joints. C. Continue moving body parts if muscle spasticity occurs. D. Stretch the body part just beyond the existing range of motion.

Correct Answer is B

Explanation

A. Move body parts rapidly through the movements. Passive range of motion (ROM) should be performed slowly and gently to prevent injury or pain.

B. Support extremities above and below joints. Supporting both above and below the joint helps prevent excessive strain and allows for controlled movement.

C. Continue moving body parts if muscle spasticity occurs. If muscle spasticity occurs, the nurse should stop and reassess before continuing, to avoid injuring the client.

D. Stretch the body part just beyond the existing range of motion. The nurse should never push beyond the client’s normal range, as this can cause pain or injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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