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 ["A","B","E"]
Explanation
Choice A rationale
Measurement of post-void residual (PVR) urine volume is a valid indication for catheterization. This procedure assesses bladder emptying efficiency, particularly in patients experiencing urinary symptoms like hesitancy or incomplete voiding. Elevated PVR volumes (typically > 100 mL) can indicate outflow obstruction or bladder dysfunction, necessitating further investigation.
Choice B rationale
Relief of urinary retention is a primary indication for catheterization. Acute urinary retention, often caused by prostatic enlargement or neurologic dysfunction, results in painful bladder distention and potential renal compromise. Catheterization promptly drains the bladder, alleviating discomfort and preventing upper urinary tract damage by reducing intravesical pressure.
Choice C rationale
Routine acquisition of a urine specimen is generally not an indication for catheterization. Clean-catch midstream urine samples are typically sufficient for most diagnostic purposes, minimizing the risk of catheter-associated urinary tract infections (CAUTIs). Catheterization is invasive and should be reserved for situations where a clean voided specimen is unobtainable or specific sterile collection is required.
Choice D rationale
Convenience for nursing staff or the patient's family is not a legitimate medical indication for urinary catheterization. Catheterization is an invasive procedure associated with significant risks, including CAUTIs, urethral trauma, and patient discomfort. Its use should be medically justified and limited to situations where benefits clearly outweigh the potential harms, prioritizing patient safety.
Choice E rationale
An open perineal wound is a strong indication for urinary catheterization. Catheterization diverts urine away from the wound, preventing contamination and promoting optimal healing. Urine is inherently acidic and can introduce bacteria, impairing tissue repair and increasing infection risk in compromised perineal tissues, making diversion crucial for wound management.
Correct Answer is C
Explanation
Choice A rationale
Breads are generally well-tolerated and do not contain substances known to irritate the bladder. They are composed primarily of carbohydrates and are not acidic or caffeinated, making them a safe dietary choice for individuals with a urinary tract infection.
Choice B rationale
While some fresh fruits are acidic, many are not strong bladder irritants and contribute to overall hydration and nutrient intake. The impact of specific fruits can vary among individuals, but generally, fresh fruits are not a universal avoidance recommendation for UTIs.
Choice C rationale
Caffeine acts as a diuretic and a bladder irritant. It can increase urinary frequency, urgency, and may exacerbate bladder discomfort and inflammation in individuals with a urinary tract infection by stimulating the bladder detrusor muscle. Therefore, it should be avoided.
Choice D rationale
Cheeses, particularly aged cheeses, do not typically contain compounds that directly irritate the bladder. They are a source of protein and fat, and generally do not contribute to urinary symptoms in the context of a urinary tract infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.