The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.

Texture

Tachypnea

Turgor

Temperature

Tympany

Answer and Explanation

Correct Answer : A,C,D

A) Texture: Assessing the texture of the skin is an important part of a comprehensive skin assessment. It provides insights into the health and hydration status of the skin. Normal skin texture should feel smooth and even, while changes can indicate issues such as dryness or conditions like eczema or psoriasis.

B) Tachypnea: This term refers to an increased respiratory rate and is not a characteristic assessed in the skin. While it can indicate a physiological response to various conditions, it does not relate to skin health or characteristics and therefore is not relevant in this context.

C) Turgor: Skin turgor refers to the elasticity and hydration status of the skin, which can be assessed by pinching the skin. Proper turgor indicates adequate hydration, while decreased turgor can signal dehydration or other health issues. This is an essential component of skin assessment.
D) Temperature: Assessing the temperature of the skin can provide information about circulation and potential inflammation or infection. Normal skin temperature should feel warm and consistent, while variations can suggest underlying conditions such as fever or shock.

E) Tympany: Tympany is a term used in percussion assessments of the abdomen and is not applicable to skin assessment. It refers to a hollow sound produced by tapping on a body surface and does not pertain to skin characteristics.

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Correct Answer is B

Explanation

A) Dietary history from the patient: This information is subjective as it relies on the patient’s personal account of their eating habits, which may be influenced by memory or perception. It does not provide measurable data.

B) BMI (Body Mass Index): This is an objective measure calculated from a person’s height and weight. It provides quantifiable data that can be used to assess nutritional status and potential health risks associated with body weight.

C) Patient history of alcohol intake: This information is subjective as it is based on the patient’s self-report. It does not provide direct evidence and may vary depending on how the patient perceives their alcohol consumption.

D) Patient complaint of weight loss: This is also subjective data, as it relies on the patient’s perception of their weight change. It does not provide concrete measurements and can be influenced by various factors such as mood or misunderstanding of the situation.

A. Low self-esteem B. His complaints of numbness in his hands C. Risk for injury D. Persistent pain

Correct Answer is C

Explanation

A) Low self-esteem: While low self-esteem can develop as a result of limitations in physical abilities, it is not the most immediate concern in this scenario. Addressing the patient's functional capabilities and safety takes precedence.

B) His complaints of numbness in his hands: Numbness is a significant symptom of carpal tunnel syndrome, but the immediate priority is to ensure the patient can safely perform tasks. While it is important to address his symptoms, managing the risk associated with his condition is more critical.

C) Risk for injury: This is the most pressing concern for the patient. Given his difficulty holding tools, there is a heightened risk of accidents or injuries while working. Prioritizing safety measures is essential to prevent harm and ensure he can continue his work safely.

D) Persistent pain: While pain management is important, the focus should be on the immediate risk of injury related to the patient's inability to hold tools securely. Addressing safety concerns takes precedence over managing pain at this point.

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The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a nutritional assessment. Which of the following would be considered objective data?

Correct Answer is B

Explanation

A patient, employed as a carpenter, has difficulty holding tools because of peripheral neuropathy from carpal tunnel syndrome. What is the nurse's priority concern for this patient?

Correct Answer is C

Explanation

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