The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)
Tachypnea
Temperature
Turgor
Tympany
Correct Answer : B,C
Normal skin temperature for healthy adults ranges between 92.3 and 98.4 Fahrenheit or 33-37 Celsius, far lower than the 98.6 F average core temp. Changes in skin temperature may indicate potential illness or injuries.
To check for skin turgor, the healthcare provider grasps the skin between two fingers so that it is tented up. Commonly the lower arm or abdomen is checked. The skin is held for a few seconds and then released. Skin with normal turgor snaps rapidly back to its normal position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.This option is appropriate for children under the age of 3. Pulling the pinna down and back straightens the ear canal in young children, but it does not align the canal correctly in adults.
B.For an adult, the correct method to straighten the ear canal during examination is to pull the pinna (outer part of the ear) up and back. This maneuver aligns the ear canal for better visualization of the tympanic membrane (eardrum) and inner structures.
C.Pulling the pinna down and forward is incorrect for both adults and children. This action would not provide a clear view of the ear canal and could make examination difficult.
D.Pulling the pinna straight back does not fully straighten the ear canal in adults and may make the examination less effective. The correct technique is up and back for adults to fully straighten the canal and enhance visualization.
Correct Answer is B
Explanation
Circumduction is a movement that involves the circular rotation of a limb, such as an arm or leg, around a fixed point. When assessing the patient's range of motion, the nurse may ask the patient to perform circumduction of their arms to evaluate their ability to move their arms in a circular motion.
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