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The nurse is assessing an elderly patient’s skin turgor and notes that it is poor.

The nurse understands that this finding may be due to which of the following reasons?

Dehydration

Malnutrition

Loss of subcutaneous fat.

Reduced collagen fibers.

Answer and Explanation

The Correct Answer is A

The correct answer is A.

Dehydration.

Poor skin turgor means that the skin takes longer to return to its normal position after being pinched or pulled.

This is a sign of dehydration, which means the body does not have enough fluid.

Dehydration can be caused by not drinking enough water, vomiting, diarrhea, fever, diabetes, or other conditions that affect fluid balance.

Choice B is wrong because malnutrition does not directly affect skin turgor.

Malnutrition means the body does not get enough nutrients from food.

This can cause various problems, such as weight loss, muscle wasting, poor wound healing, and infections.

However, malnutrition does not cause the skin to lose its elasticity.

Choice C is wrong because loss of subcutaneous fat does not cause poor skin turgor.

Subcutaneous fat is the layer of fat under the skin that helps insulate the body and store energy.

As people age, they tend to lose some subcutaneous fat, especially in the face and hands.

This can make the skin look thinner and more wrinkled, but it does not affect how quickly the skin snaps back after being pinched.

Choice D is wrong because reduced collagen fibers do not cause poor skin turgor.

Collagen is a protein that gives the skin its strength and structure.

As people age, they produce less collagen, which can make the skin sag and lose firmness.

However, collagen does not affect the skin’s ability to retain water and return to its normal shape after being stretched.

Normal ranges for skin turgor vary depending on the age and location of the skin.

In general, healthy skin should return to its normal position within 2 seconds after being pinched.

In children and young adults, skin turgor can be tested on the abdomen or forearm. In elderly people, skin turgor can be tested on the clavicle (collar bone), sternum (breastbone), forehead, or inner thigh. These sites are less affected by skin wrinkling and aging.

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Correct Answer is D

Explanation

The correct answer is D.

All of the above.

The nurse should ask all of these questions to assess the possible causes of the client’s condition.

Depression and social isolation in older adults can be triggered by various factors, such as:.

• Losses or changes in life, such as death of a spouse, retirement, relocation, or chronic illness.

• Lack of social support or contact with family, friends, or neighbors, which can lead to loneliness and reduced self-esteem.

• Decreased engagement or interest in activities or hobbies that provide meaning, pleasure, or stimulation, which can affect mood and cognitive function.

By asking these questions, the nurse can identify the specific factors that contribute to the client’s depression and social isolation, and provide appropriate interventions to address them.

For example, the nurse can:.

• Provide emotional support and empathy to the client and help them cope with their losses or changes.

• Encourage the client to maintain or increase their social interactions and connections with others who share similar interests or experiences.

• Assist the client to resume or find new activities or hobbies that suit their abilities and preferences, and provide positive feedback and reinforcement.

A. Increased skin turgor. B. Decreased pulse rate C. Increased urine output. D. Decreased mental status.

Correct Answer is D

Explanation

The correct answer is D.

Decreased mental status.Dehydration in elderly people can cause confusion, disorientation, or drowsiness due to the loss of water and electrolytes from the body.

These symptoms can affect the cognitive function and alertness of the client.Dehydration can also lead to complications such as kidney problems, electrolyte imbalances, or low blood pressure.

Choice A is wrong because increased skin turgor is not a sign of dehydration.

Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled.Dehydration causes decreased skin turgor, meaning the skin stays tented or wrinkled after being pinched.

Choice B is wrong because decreased pulse rate is not a sign of dehydration.Dehydration causes increased pulse rate, as the heart has to work harder to pump blood to the vital organs when there is less fluid in the body.

Choice C is wrong because increased urine output is not a sign of dehydration.Dehydration causes decreased urine output, as the kidneys try to conserve water and produce more concentrated urine.

The urine may also be darker in color than normal.

Normal ranges for fluid intake and output vary depending on age, weight, activity level, and health status.

However, a general guideline is to drink at least eight 8-ounce glasses of water per day and produce at least 30 mL of urine per hour.

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The nurse is assessing an elderly patient’s skin turgor and notes that it is poor.

The nurse understands that this finding may be due to which of the following reasons?