The nurse cares for an older adult client with dry mucus membranes and cracked lips. What action should the nurse take first?
Encourage the client to increase fluid intake.
Notify the healthcare provider.
Assess skin turgor over the abdomen.
Assess skin turgor at the clavicle.
The Correct Answer is D
A. Encouraging the client to increase fluid intake may be appropriate, but it is not the first action. Before interventions, the nurse must assess the extent of dehydration to determine appropriate care and prevent complications like fluid overload or electrolyte imbalance.
B. Notifying the healthcare provider may be necessary depending on the assessment findings, but it is not the initial step. The nurse must first collect objective data to guide clinical decision-making.
C. Assessing skin turgor over the abdomen is a traditional method for evaluating hydration, but in older adults, skin loses elasticity, making abdominal turgor less reliable. This may lead to underestimation or overestimation of dehydration severity.
D. Assessing skin turgor at the clavicle (or sternum) is recommended for older adults, as these areas are less affected by age-related changes in skin elasticity. Checking skin turgor here provides a more accurate assessment of hydration status, helping guide subsequent interventions such as fluid administration or provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
A. The difference between the systolic and diastolic pressures is referred to as the pulse pressure, calculated by subtracting diastolic from systolic pressure (e.g., 140 – 90 = 50 mmHg). While pulse pressure provides useful information about arterial compliance and stroke volume, it does not define systolic pressure itself. Therefore, this statement does not reflect correct understanding of the systolic reading.
B. The pressure in the veins when the ventricles are contracting is incorrect. Venous pressure is generally low and does not fluctuate significantly with ventricular contraction, unlike arterial pressure. Systolic pressure is measured in the arteries, not veins, so this option demonstrates a misunderstanding.
C. The pressure in the veins when the ventricles are pushing blood forward is also incorrect for the same reason. Venous pressure is largely influenced by venous return and right atrial pressure, not the force of ventricular contraction. Systolic pressure refers exclusively to arterial pressure during ventricular contraction, not venous pressure.
D. The pressure in the arteries when the ventricles are pushing blood forward is correct. During ventricular systole, the left ventricle contracts, propelling blood into the aorta and systemic arteries, which creates the highest pressure in the arterial system. This peak arterial pressure is recorded as the systolic value in a blood pressure reading.
E. The pressure in the arteries when the ventricles are contracting is also correct. “Contracting” is another way of describing ventricular systole. Systolic pressure represents the maximum arterial pressure generated during this phase of the cardiac cycle, making this statement accurate.
Correct Answer is B
Explanation
A. Pulling the pinna forward and up does not effectively straighten the adult ear canal. The external auditory canal in adults has a natural upward and forward curve, so pulling forward does not properly align the canal for visualization of the tympanic membrane.
B. In adults (and children older than 3 years), the nurse should pull the pinna up and back when inserting the otoscope. This maneuver straightens the S-shaped external auditory canal, allowing clear visualization of the tympanic membrane. Proper positioning reduces discomfort and prevents injury during the examination.
C. Pulling the pinna down and back is appropriate for infants and young children under 3 years of age. In this age group, the ear canal is shorter and more horizontal. Using this technique on an adult would not properly align the canal.
D. Leaving the pinna in its natural position does not straighten the ear canal, making visualization of the tympanic membrane more difficult and potentially uncomfortable for the client.
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