A nurse performing an integumentary inspection on a client gently pinches the skin in the chest area. The nurse is assessing which of the following:

Skin moisture

Skin texture

Skin turgor

Skin vascularity

Answer and Explanation

The Correct Answer is C

A. Skin moisture: Moisture is assessed by observing and lightly touching the skin surface (dry, diaphoretic), not by pinching for elasticity.

B. Skin texture: Texture (smooth, rough) is assessed by stroking or palpating the skin surface, usually with fingertips rather than by the pinch test.

C. Skin turgor: Turgor (elasticity / how quickly skin returns to place after being pinched) is directly evaluated by pinching the skin and noting how it recoils.

D. Skin vascularity: Vascularity (color, capillary refill) is assessed by inspection and capillary refill testing, not by pinching for elasticity.

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Correct Answer is D

Explanation

A. Tachycardia: Tachycardia is a rapid heart rate; it describes pulse, not the positional dyspnea the client reports.

B. Retractions: Retractions are visible inward movement of chest wall with respiratory effort and indicate severe respiratory distress; the report of dyspnea when supine is better described by a different term.

C. Tachypnea: Tachypnea is rapid breathing (increased respiratory rate); the symptom described is difficulty breathing while supine, not specifically an increased rate.

D. Orthopnea: Orthopnea is shortness of breath that occurs or worsens when lying flat and improves when upright; documenting orthopnea matches the symptom of sudden dyspnea in the supine position.

A. Family members should always be present B. There are no special considerations when conducting a physical assessment C. The door to the room is left open D. The room is private, warm, with adequate lighting

Correct Answer is D

Explanation

A. Family members should always be present: Family presence is optional and should depend on patient preference and confidentiality concerns - it is not mandatory.

B. There are no special considerations when conducting a physical assessment: Physical assessments require attention to privacy, patient comfort, and safety - so special considerations do apply.

C. The door to the room is left open: Leaving the door open can breach privacy and confidentiality and may make the patient uncomfortable.

D. The room is private, warm, with adequate lighting: A private, warm room with good lighting promotes patient comfort, dignity, and an accurate examination.

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A nurse performing an integumentary inspection on a client gently pinches the skin in the chest area. The nurse is assessing which of the following:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is D

Explanation

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