During the nursing assessment of an older adult's skin turgor, what should the nurse keep in mind?
Older adults' skin turgor is moist and boggy.
Skin turgor is unaffected by aging.
Decrease in elasticity on skin turgor is a normal part of aging.
Assessment should only be performed on the hands of older adults.
The Correct Answer is C
Choice A rationale
Older adults' skin turgor is typically not moist and boggy. Instead, it often presents with decreased elasticity and may appear lax due to age-related changes in collagen and elastin fibers. Boggy skin turgor can indicate significant fluid retention or edema, which is not a normal physiological finding associated with aging alone.
Choice B rationale
Skin turgor is significantly affected by aging. The dermis thins, and there is a reduction in collagen and elastin, leading to a loss of skin elasticity. This physiological process results in decreased turgor, making the skin appear less resilient and more prone to tenting, reflecting normal age-related changes.
Choice C rationale
A decrease in elasticity on skin turgor is a normal part of aging. As individuals age, there is a natural reduction in the quantity and quality of elastin and collagen fibers within the dermal layer of the skin. This leads to diminished recoil capacity, manifesting as prolonged tenting when the skin is pinched, which is a expected finding.
Choice D rationale
Assessing skin turgor only on the hands of older adults is not the most reliable approach. Due to age-related loss of subcutaneous fat and decreased elasticity, the hands can often show false positives for dehydration. The sternum or forehead provides a more accurate assessment site for evaluating hydration status in the elderly population because these areas are less affected by typical age-related changes in skin elasticity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While increased fluid intake helps flush bacteria from the urinary tract, encouraging 8 ounces of water every hour could lead to excessive fluid intake (polydipsia) and electrolyte imbalances, specifically hyponatremia, which is not a normal physiological state. A more balanced hydration strategy is generally recommended to prevent urinary tract infections.
Choice B rationale
Proper perineal hygiene, specifically wiping from front to back, is crucial for female patients because it prevents the transfer of fecal bacteria (e.g., Escherichia coli) from the anal region to the urethral opening. The female urethra is short and in close proximity to the anus, making it highly susceptible to ascending bacterial infections without this practice.
Choice C rationale
Using bath powder can introduce foreign particles and potentially irritating substances into the sensitive perineal area, which may disrupt the natural microbial balance and increase the risk of irritation or infection, rather than preventing urinary tract infections. Moisture absorption is better managed through breathable undergarments and good hygiene.
Choice D rationale
Advising patients to hold urine for extended periods can lead to urinary stasis, where urine remains in the bladder for too long, allowing bacteria more time to multiply and ascend the urinary tract. Regular and complete bladder emptying is essential for flushing out potential pathogens and reducing the risk of urinary tract infections.
Correct Answer is D
Explanation
Choice A rationale
Cerebral angiography involves injecting contrast into cerebral arteries to visualize blood vessels, primarily used for conditions like aneurysms or arteriovenous malformations. While some vascular abnormalities can cause seizures, it is not the primary diagnostic test for initial seizure disorder evaluation.
Choice B rationale
Electromyography (EMG) measures the electrical activity of muscles in response to nerve stimulation. It is used to diagnose neuromuscular disorders, such as myasthenia gravis or peripheral neuropathies, and is not the primary diagnostic tool for a seizure disorder.
Choice C rationale
A lumbar puncture involves collecting cerebrospinal fluid (CSF) for analysis, primarily used to diagnose infections, inflammatory conditions, or certain neurological disorders. While it might be performed in some seizure contexts to rule out infection, it is not the initial or primary test for seizure disorder diagnosis.
Choice D rationale
Electroencephalography (EEG) records the electrical activity of the brain. It is the gold standard for diagnosing seizure disorders because it can detect abnormal neuronal discharges characteristic of seizures and help classify seizure types, providing crucial information for treatment planning.
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