The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?
Skin fold is difficult to lift/pinch.
Skin fold is released and an indentation of 2 mm remains.
Skin fold returns to its usual shape quickly when released.
Skin fold returns to its usual shape slowly when released.
The Correct Answer is C
The correct answer is choice C: Skin fold returns to its usual shape quickly when released. When assessing skin turgor, the nurse is checking for the elasticity and hydration of the skin. In a normal assessment, when the skin fold is lifted or pinched, it should return to its usual shape quickly when released. This indicates good skin turgor, which is an indication of proper hydration. If the skin fold is difficult to lift or pinch (choice A), this indicates poor skin turgor and possible dehydration. If an indentation of 2 mm remains after releasing the skin fold (choice B), this indicates poor skin turgor and possible dehydration. If the skin fold returns to its usual shape slowly when released (choice D), this may indicate a decrease in skin elasticity and possible dehydration.
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Related Questions
Correct Answer is B
Explanation
A. Along either upper gum line, adjacent to an incisor:Placing the thermometer along the upper gum line near the incisors would not accurately reflect the body's core temperature. The posterior sublingual pocket provides a more reliable reading.
B. Deep in the posterior sublingual pocket:The sublingual pocket, located under the tongue toward the back, is the best place for measuring oral temperature. This area has a good blood supply from the carotid arteries, making it ideal for an accurate temperature reading.
C. In the inferior buccal space on either side of the tongue:The buccal space is not ideal for temperature measurement, as it does not have the same consistent blood supply and is more prone to error due to airflow from breathing.
D. Superior to the tongue with the tip touching the hard palate:Placing the thermometer on top of the tongue against the hard palate would result in an inaccurate reading because this location does not effectively reflect the body's core temperature.
Correct Answer is D
Explanation
A. 2+ Pitting Edema:This refers to moderate pitting edema where the indentation is approximately 4 mm and disappears within 10-15 seconds.
B. 3+ Pitting Edema:This refers to moderately severe pitting edema where the indentation is approximately 6 mm and may last longer than 1 minute but does not remain for as long as 4 minutes.
C. 1+ Non-Pitting Edema:This grade refers to mild pitting edema with a 2 mm indentation that quickly disappears within a few seconds.
D. 4+ Pitting Edema:4+ pitting edema is characterized by a very deep pit (approximately 8 mm) that may last 2-5 minutes or more. This matches the scenario where the pit is 8 mm deep and remains for 4 minutes.
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