The nurse finds that a patient’s skin tents when assessing skin turgor. How would the nurse interpret this finding?

Malnutrition

Overhydration

Severe edema

Severe dehydration

Answer and Explanation

The Correct Answer is D

Choice A reason: Malnutrition may cause skin changes like dryness or thinning but does not typically cause tenting. Tenting reflects loss of skin elasticity due to fluid deficit, not primarily nutritional deficiency, making this an incorrect interpretation of the finding.

Choice B reason: Overhydration causes skin edema, leading to pitting or swelling, not tenting. Tenting occurs when skin lacks moisture and elasticity, which is the opposite of fluid excess, making this an incorrect interpretation of the observed skin turgor.

Choice C reason: Severe edema results in swollen, pitting skin due to fluid retention, not tenting. Tenting indicates a lack of interstitial fluid, as seen in dehydration, making this an incorrect interpretation of the skin turgor finding.

Choice D reason: Skin tenting, where skin slowly returns to its normal position after pinching, indicates severe dehydration. This occurs due to reduced interstitial fluid and loss of skin elasticity, commonly seen in significant fluid loss, making this the correct interpretation.

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Correct Answer is C

Explanation

Choice A reason: Cranial Nerve V (trigeminal) controls facial sensation and chewing muscles. It has no role in hearing, which is tested by the whispered voice test, making this an incorrect choice for assessing auditory function.

Choice B reason: Cranial Nerve II (optic) is responsible for vision, not hearing. The whispered voice test evaluates auditory acuity, which is unrelated to visual function, making this an incorrect cranial nerve for the assessment.

Choice C reason: Cranial Nerve VIII (vestibulocochlear) mediates hearing and balance. The whispered voice test assesses the cochlear branch’s ability to transmit sound, making this the correct cranial nerve evaluated by this hearing test.

Choice D reason: Cranial Nerve IV (trochlear) controls the superior oblique eye muscle, affecting eye movement. It is unrelated to hearing, which the whispered voice test assesses, making this an incorrect choice for the described evaluation.

A. Tricuspid and Aortic B. Mitral and Tricuspid C. Aortic and Pulmonic D. Pulmonic and Mitral

Correct Answer is C

Explanation

Choice A reason: The S2 sound is produced by the closure of aortic and pulmonic valves, not tricuspid and aortic. Tricuspid closure contributes to S1, so this is incorrect for the S2 heart sound.

Choice B reason: Mitral and tricuspid valve closure produce the S1 sound, not S2. Aortic and pulmonic valves close during diastole, creating S2, so this incorrect for the second heart sound.

Choice C reason: The S2 sound results from the closure of the aortic and pulmonic valves at the end of systole, marking diastole’s start. This is the standard mechanism, making it the correct choice for S2.

Choice D reason: Pulmonic and mitral valves don’t close simultaneously; mitral closes for S1, pulmonic for S2. Aortic and pulmonic valves form S2, so this is incorrect for the heart sound.

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The nurse finds that a patient’s skin tents when assessing skin turgor. How would the nurse interpret this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse uses the whispered voice test to assess a patient’s hearing. The nurse is assessing which cranial nerve?

Correct Answer is C

Explanation

Which valves of the heart create the S2 heart sound?

Correct Answer is C

Explanation

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