In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?
Assess the degree of skin elasticity.
Record palpated skin temperature.
Measure the depth of indentation.
Observe for swelling and inflammation.
The Correct Answer is A
A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A warm sleeping environment may exacerbate pruritus by increasing skin dryness and irritation. Cool, comfortable environments are generally better for clients with pruritus.
B. Keeping fingernails trimmed short helps prevent skin damage and infection caused by scratching. This is a practical and effective measure to manage pruritus.
C. Discouraging the use of skin lubricants is not advisable as they can help soothe and moisturize dry, itchy skin. Emollients and moisturizers are often recommended to manage pruritus.
D. Advising against any type of tub bath is not necessary. Instead, the use of lukewarm baths with added colloidal oatmeal or other soothing agents can help reduce pruritus.
Correct Answer is D
Explanation
A. Monitoring daily sodium intake is important for managing AKI, but it is not the immediate priority when addressing acute changes in heart rate and blood pressure.
B. Recording usual eating patterns is not relevant to the immediate concern of elevated heart rate and blood pressure in the context of AKI.
C. Documenting abdominal girth is relevant for assessing fluid status and potential complications like ascites, but it is not the first priority for addressing the acute symptoms of elevated heart rate and blood pressure.
D. Measuring and documenting urinary output is the most critical intervention because it provides essential information on kidney function and fluid balance, which directly impacts heart rate and blood pressure management in AKI.
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