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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Breathing difficulty is the highest priority, as it affects oxygenation, a life-threatening issue. Pain is next, impacting comfort and recovery, followed by sleep, which supports healing. This follows the ABC (Airway, Breathing, Circulation) prioritization, making it the correct order for addressing the patient’s issues.
Choice B reason: Prioritizing sleep over pain after breathing is incorrect; pain is more urgent, as it distresses and affects recovery, while sleep is secondary. Breathing remains first, but pain precedes sleep, so this is incorrect for prioritization.
Choice C reason: Sleep as the first priority ignores breathing, a critical life-threatening issue. Breathing and pain are more urgent, with sleep supporting long-term recovery, so this is incorrect for acute care prioritization principles.
Choice D reason: Placing sleep first and breathing last disregards life-threatening breathing issues. Breathing, then pain, then sleep align with ABC priorities, ensuring patient patient safety, so this is incorrect for the nurse’s approach.
Correct Answer is D
Explanation
Choice A reason: Convergence and pupil constriction are accommodation reflexes, not corneal light reflex, which tests alignment. Light reflection symmetry indicates eye alignment, so this incorrect for the reflex’s purpose.
Choice B reason: Pupil constriction is a pupillary reflex, not corneal light reflex. The corneal reflex involves light reflection on corneas, assessing alignment, not pupil response, so this is incorrect.
Choice C reason: Macular focus is related to visual acuity, not corneal reflex, light reflex, which checks eye alignment via light reflection. Symmetric reflection is key, so this incorrect for the reflex’s indication.
Choice D reason: A normal corneal reflex shows light reflecting in the same spot on both corneas, indicating proper eye alignment. This is the definition of the reflex, making it the correct choice for eye assessment.
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