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
Objective data refers to measurable and observable information gathered during a patient assessment, such as physical signs, laboratory values, and other measurable data. In this case, the loss of hair on bilateral legs can be observed and measured, making it an objective finding. Options a, c, and d are all subjective data as they rely on the patient's report or description of their symptoms, which cannot be directly observed or measured.
Correct Answer is ["B","C","D"]
Explanation
Assessing unilaterally is not recommended as it may lead to missing important findings on one side.
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