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

Explanation

A. Identify when the client first noticed the lesion. Determining onset and duration helps assess whether the lesion is new, growing, or concerning for malignancy.

B. Photograph the lesion for the client's medical record. While documentation is important, assessing history and changes in the lesion takes priority.

C. Instructing the client on the use of daily sunscreen products. Sunscreen is essential for prevention, but identifying and assessing the lesion comes first.

D. Document the client's history of skin allergies. While important, it does not take priority over determining how long the lesion has been present and whether it is changing.

A. Urinary frequency B. Urinary tract infection C. Urinary retention D. Urinary incontinence

Correct Answer is B

Explanation

A. Urinary frequency. Urinary frequency is an increased urge to void, which can be caused by a UTI but does not explain cloudy, foul-smelling urine on its own.

B. Urinary tract infection (UTI). Cloudy, dark amber urine with a foul odor is indicative of a UTI due to bacterial presence, pus (pyuria), and possibly hematuria.

C. Urinary retention. Urinary retention leads to distended bladder, incomplete emptying, and overflow incontinence, but it does not cause foul-smelling, cloudy urine unless it leads to secondary infection.

D. Urinary incontinence. Incontinence is the involuntary loss of urine, but it does not cause cloudy or foul-smelling urine unless there is an underlying infection.

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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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