The nurse assessing a 90-year-old patient notes that his skin is thin and turgor is non-elastic. The patient states that he always seems to be cold. What does the nurse know about these assessment findings?

The patient's integumentary system is within normal limits for his age

The patient may have a metabolic condition causing him to feel cold

The patient has abnormal thinning of skin

The patient should have elastic turgor

Answer and Explanation

The Correct Answer is B

A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.
B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.

C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.

D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.

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Correct Answer is C

Explanation

A) Notify the healthcare provider that the client is exaggerating their pain: It is inappropriate for the nurse to assume that the client is exaggerating their pain based solely on their demeanor. Pain perception is subjective and can vary greatly among individuals, especially in conditions like sickle cell anemia.

B) Wait 30 minutes and see if the client is still requesting pain medication: Delaying pain relief can lead to unnecessary suffering. Given that the client rates their pain as a 7 out of 10, which indicates significant discomfort, it is essential to address their pain promptly rather than postponing treatment.

C) Administer the pain medication as prescribed: This is the most appropriate action. Clients with sickle cell anemia often experience severe pain crises, and effective pain management is crucial. Administering the medication as prescribed supports the client's comfort and well-being.

D) Administer half of the ordered dose of pain medication: Modifying the dosage without a provider's order is not appropriate. If the full prescribed dose is warranted based on the pain level, the nurse should administer it as indicated to ensure effective pain management.

A. This would indicate pitting edema B. This may indicate dehydration, but might not be reliable in an older adult C. This means the client is well hydrated D. This indicates peripheral neuropathy

Correct Answer is B

Explanation

A) This would indicate pitting edema: Tenting is not indicative of pitting edema, which is characterized by a depression left in the skin after pressure is applied. Tenting specifically refers to the skin's elasticity and is assessed by pinching the skin, observing how quickly it returns to its normal position.

B) This may indicate dehydration, but might not be reliable in an older adult: Tenting is often a sign of dehydration, as it reflects decreased skin elasticity. However, in elderly individuals, skin changes due to aging (like reduced elasticity and moisture) may make this assessment less reliable. Factors such as medications, health status, and overall skin integrity can also influence this observation, making it necessary to consider other indicators of hydration.
C) This means the client is well hydrated: Tenting does not indicate adequate hydration. In fact, it typically suggests the opposite, as well-hydrated skin should return to normal quickly after being pinched.

D) This indicates peripheral neuropathy: While peripheral neuropathy can affect skin and tissue integrity, tenting specifically relates to skin turgor and elasticity rather than nerve function. Tenting is not a direct indicator of neuropathy; other assessments would be needed to evaluate nerve health.

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The nurse assessing a 90-year-old patient notes that his skin is thin and turgor is non-elastic. The patient states that he always seems to be cold. What does the nurse know about these assessment findings?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has pain due to sickle cell anemia. The patient rates the pain as a 7 out of 10 (O is no pain and 10 is the worst pain possible). The client is moving around easily and smiling. She is asking for pain medication. Which action by the nurse is most appropriate?

Correct Answer is C

Explanation

When assessing the skin of an elderly client, the nurse notes tenting. The nurse understands what about this assessment?

Correct Answer is B

Explanation

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