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 ["A","C","E"]

Explanation

A. Check the client's toes for color, temperature, and sensation: Assesses neurovascular status to detect signs of impaired circulation or nerve injury.

B. Apply heat to the client's ankle: Heat can increase swelling; ice should be used instead (RICE method: Rest, Ice, Compression, Elevation).

C. Apply a compression bandage to the client's ankle: Helps reduce swelling and provides support.

D. Encourage range of motion of the client's foot: Movement may worsen injury if a fracture or soft tissue damage is present.

E. Elevate the client's foot: Reduces swelling by promoting venous return.

A. Stress incontinence B. Reflex incontinence C. Urge incontinence D. Overflow incontinence

Correct Answer is A

Explanation

A. Stress incontinence. Stress incontinence occurs when intra-abdominal pressure (e.g., sneezing, coughing, laughing) causes urine leakage due to weak pelvic floor muscles or urethral sphincter dysfunction.

B. Reflex incontinence. Reflex incontinence is involuntary urination without warning due to neurological dysfunction (e.g., spinal cord injury, multiple sclerosis), which is not the case here.

C. Urge incontinence. Urge incontinence is a sudden, intense need to urinate, often caused by overactive bladder syndrome or neurological disorders. It is not associated with sneezing.

D. Overflow incontinence. Overflow incontinence occurs when the bladder fails to empty completely, leading to dribbling of urine due to urinary retention (e.g., BPH, diabetic neuropathy).

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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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