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 ["A","B","C","D","E"]
Explanation
The correct answer isA, B, C, D, and E.
All of these questions are relevant for conducting a psychosocial assessment of an older adult client who has recently retired from work.A psychosocial assessment is a process for learning about a client’s problems and needs, so that together you can create therapy goals and a plan for recovery.The information-gathering process should allow you to learn more about the client as a person, beyond just a diagnosis.
• Choice A is correct because it explores how the client feels about their retirement, which can be a major life transition that affects their identity, self-esteem, and sense of purpose.
• Choice B is correct because it assesses the client’s interests and hobbies, which can provide sources of enjoyment, stimulation, and meaning in their life.
• Choice C is correct because it evaluates the client’s social support network, which can influence their mental health, well-being, and coping skills.
• Choice D is correct because it identifies the client’s stressors and challenges, which can affect their mood, functioning, and quality of life.
• Choice E is correct because it examines the client’s physical and mental health issues, which can impact their ability to perform daily activities, manage their emotions, and adhere to treatment plans.
A comprehensive geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of older people.The comprehensive geriatric assessment specifically and thoroughly evaluates functional and cognitive abilities, social support, financial status, and environmental factors, as well as physical and mental health.Ideally, a regular examination of older patients incorporates many aspects of the comprehensive geriatric assessment, making the two approaches very similar.
Correct Answer is D
Explanation
The correct answer isD.
All of the above.
The nurse should take all of the actions listed to provide effective pain management for the older adult client who has depression and chronic pain in his lower back.
• Choice Ais correct because assessing the pain using a valid and reliable pain scale is essential for determining the severity and impact of pain, as well as monitoring the response to treatment.
• Choice Bis correct because administering analgesic medications as prescribed can help reduce pain and improve function.
The nurse should also monitor for effectiveness and side effects, especially in older adults who may have altered drug metabolism, polypharmacy, and increased risk of adverse events.
• Choice Cis correct because providing non-pharmacological interventions can enhance pain relief, reduce medication use, and address the biopsychosocial aspects of pain.
Massage, heat or cold therapy, relaxation techniques, and distraction are some examples of non-pharmacological interventions that can be used for chronic pain in older adults.
• Choice Dis correct because it includes all of the above actions, which are part of a multimodal approach to pain management that is recommended by clinical guidelines.
4 7 A multimodal approach can improve pain outcomes, reduce side effects, and address the complex needs of older adults with chronic pain.
A. Assess the location, intensity, quality and duration of the pain using a pain scale B.
Administer analgesic medications as prescribed and monitor for effectiveness and side effects C.
Provide non-pharmacological interventions such as massage, heat or cold therapy, relaxation techniques or distraction D.
All of the above
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