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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Prevent distortion of bowel sounds. – Palpation can stimulate peristalsis and alter bowel sounds, leading to inaccurate assessment findings.
B. Prevent distortion of vascular sounds. – While palpation might affect vascular sounds slightly, this is not the primary concern when assessing the abdomen.
C. Determine any areas of tenderness or pain. – While assessing for tenderness is important, auscultation precedes palpation primarily to avoid altering bowel sounds.
D. Allow the patient to relax and be comfortable. – While relaxation is beneficial, the sequence of assessment is based on maintaining accuracy in findings rather than patient comfort.
Correct Answer is D
Explanation
A. Percussion – Percussion involves tapping the body to assess underlying structures, not feeling for texture or consistency.
B. Auscultation – Auscultation is listening to body sounds (e.g., heart, lungs, and bowels) using a stethoscope, not feeling structures.
C. Inspection – Inspection is visual observation, not a tactile assessment.
D. Palpation – Palpation involves using the hands to assess the texture, size, consistency, and location of body structures, such as organs or lymph nodes.
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