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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Encourage fluid intake of at least 2 L/day.
This is because adequate hydration can help soften the stool and facilitate its passage through the intestines.Fluid intake should be increased gradually to avoid fluid overload or electrolyte imbalance.
Choice B is wrong because alow-fiber dietcan contribute to constipation by reducing the bulk and water content of the stool.
Fiber helps retain water in the stool and stimulate peristalsis.A high-fiber diet is recommended for clients who have constipation.
Choice C is wrong because astimulant laxativeshould not be used daily or for a long period of time, as it can cause dependence, dehydration, electrolyte imbalance, and damage to the intestinal mucosa.Stimulant laxatives should be used only as a last resort when other measures fail.
Choice D is wrong becausephysical activitycan help prevent constipation by increasing intestinal motility and blood flow.Physical activity should be encouraged for clients who have constipation, unless contraindicated by other conditions.
Normal ranges for fluid intake are about 2 to 3 L/day for adults, depending on age, weight, activity level, and climate.Normal ranges for fiber intake are about 25 to 38 g/day for adults, depending on age and sex.
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