The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

Press the skin over the client's ankle bone

Lightly palpate the skin using the fingertips

Grasp a fold of skin on the client's forearm or near the sternum

Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen

Answer and Explanation

The Correct Answer is C

A. Press the skin over the client's ankle bone. – The skin over bony prominences does not provide an accurate assessment of turgor due to reduced subcutaneous tissue in elderly clients.

B. Lightly palpate the skin using the fingertips. – Light palpation assesses texture and moisture but does not evaluate skin turgor.

C. Grasp a fold of skin on the client’s forearm or near the sternum. – Skin turgor is best assessed by gently pinching the skin on the forearm or sternum. Delayed return to normal indicates dehydration or decreased skin elasticity due to aging.

D. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. – This describes petechiae, which indicate capillary fragility or bleeding disorders, not skin turgor.

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Correct Answer is A

Explanation

A. Edema. – Edema refers to fluid buildup in the interstitial spaces, leading to swelling in tissues. It can be caused by conditions such as heart failure, kidney disease, or inflammation.

B. Ecchymosis. – Ecchymosis refers to bruising caused by blood leakage into subcutaneous tissue, not fluid accumulation.

C. Pallor. – Pallor describes an abnormal pale appearance of the skin, often due to anemia or shock, rather than fluid accumulation.

D. Erythematosis. – Erythematosis is associated with redness and inflammation, not fluid retention.

A. Dizziness especially when rising from a sitting position B. Blood pressure 145/84 C. Unexplained weight gain since his last clinic visit 1 month ago D. Exertional dyspnea E. Has been sleeping on 2 pillows for the past 2 weeks F. 2+ edema in J.M's legs

Correct Answer is ["B","C","F"]

Explanation

A. Dizziness, especially when rising from a sitting position – Dizziness is a subjective symptom reported by the patient rather than an objectively observed sign.

B. Blood pressure 145/84 – Blood pressure is an objective measurement and is considered a sign because it can be directly observed and recorded.

C. Unexplained weight gain since his last clinic visit 1 month ago – Weight gain is a measurable and observable change, making it a sign, especially in conditions like heart failure.

D. Exertional dyspnea – Exertional dyspnea (shortness of breath with activity) is a subjective experience reported by the patient, making it a symptom rather than a sign.

E. Has been sleeping on 2 pillows for the past 2 weeks – The need for multiple pillows to relieve breathing difficulty (orthopnea) is a subjective symptom, not an observable sign.

F. 2+ edema in J.M.'s legs – Edema (swelling) is an observable physical finding, making it a sign. It is commonly associated with heart failure and fluid retention.

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The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

An abnormal accumulation of fluid in the interstitial spaces is described as:

Correct Answer is A

Explanation

A nurse is collecting data from a 70-year-old man who has coronary artery disease (CAD) and hypertension (HTN) Which of the following findings will the nurse report as "signs?" (select all that apply)

Correct Answer is ["B","C","F"]

Explanation

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