The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?

Apply a lubricating lotion to the skin.

Pad all bony prominences.

Encourage a high protein diet.

Bathe with a mild soap daily.

Answer and Explanation

The Correct Answer is A

A. Applying a lubricating lotion helps to combat dryness and maintain skin moisture, which is particularly beneficial as skin turgor decreases with age. This is a direct way to address common skin issues in older adults.
B. Padding bony prominences helps to prevent pressure ulcers but does not address the issue of decreased skin turgor directly.
C. Encouraging a high-protein diet is beneficial for overall skin health and repair but is not specifically aimed at addressing the immediate changes in skin turgor due to aging.
D. Bathing with mild soap is gentle on the skin but does not specifically address the loss of skin turgor. Using a lotion or moisturizer directly addresses the dryness and potential discomfort associated with aging skin.

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Correct Answer is B

Explanation

A. Impaired bed mobility is a concern, especially for an immobile client, but addressing fluid volume deficit takes precedence due to its immediate impact on the client's health.
B. Fluid volume deficit is a critical issue, particularly with diarrhea, which can lead to dehydration and electrolyte imbalances. Ensuring adequate fluid intake and managing fluid balance is essential for preventing complications.
C. Bowel incontinence is a significant issue but managing fluid volume deficit is more urgent to prevent potential complications from dehydration.
D. Caregiver role strain is important, but the immediate priority should be addressing the client’s health needs, such as preventing and managing fluid volume deficit, which can impact overall well-being.

A. Reduce the amount of pressure being applied on the top of the foot. B. Palpate the site on the inner side of the ankle below the medial malleolus. C. Obtain a doppler stethoscope to auscultate the pulse at the same site. D. Document in the nurses' notes that the dorsalis pedis pulse is not palpable.

Correct Answer is A

Explanation

A. Reducing the amount of pressure applied is the appropriate next step because excessive pressure can occlude the pulse, making it difficult to feel. Lightening the pressure may help the nurse detect the pulse.
B. Palpating the posterior tibial pulse (below the medial malleolus) is another option if the dorsalis pedis pulse is not palpable, but it should be attempted only after ensuring that proper technique was used to feel the dorsalis pedis pulse.
C. Using a Doppler stethoscope is a good option if the pulse remains non-palpable after proper technique has been used. However, it is not the immediate next step.
D. Documenting that the dorsalis pedis pulse is not palpable should be done after all appropriate steps, including adjusting the pressure and possibly using a Doppler, have been attempted.

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The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is B

Explanation

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?

Correct Answer is A

Explanation

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