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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.
Correct Answer is A
Explanation
A pureed diet is a type of texture-modified diet where food is blended to a smooth consistency to make it easier to swallow. Nectar-thick liquids are liquids that have a slightly thicker consistency than water, which makes them easier for the client to swallow without choking or aspirating.
Options B, C, and D are not appropriate for a client with dysphagia on a pureed diet with nectar-thick liquids. Corn on the cob is a hard, crunchy food that is difficult to puree, while a hamburger and a salad are both difficult to make into a smooth consistency. These foods could pose a choking or aspiration risk for the client.
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