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 C

Explanation

A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.

B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.

C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.

D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.

A. Splint and immobilize the extremity B. Apply an ice pack to the ankle C. Encourage weight bearing and ambulation D. Assess pulse, color, temperature and capillary refill

Correct Answer is D

Explanation

A) Splint and immobilize the extremity: While immobilizing the injured extremity is important to prevent further injury, it should follow an initial assessment of blood flow and nerve function to ensure there are no vascular or neurological compromises.

B) Apply an ice pack to the ankle: Applying ice can help reduce swelling and alleviate pain. However, it is essential first to assess the circulation to the limb to ensure that applying ice will not worsen any underlying issues.

C) Encourage weight bearing and ambulation: Encouraging weight bearing on a potentially injured ankle can lead to further damage and is not appropriate. The priority is to assess the injury and understand its severity.

D) Assess pulse, color, temperature, and capillary refill: This step is crucial as it evaluates the vascular status of the limb. Assessing these factors helps identify any potential complications, such as compartment syndrome or inadequate blood flow, and guides further management of the injury.

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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 caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which intervention will the nurse implement?

Correct Answer is C

Explanation

A patient is in the ED after falling off a ladder. His ankle appears swollen, out of alignment, and is painful to touch. What will the nurse do first?

Correct Answer is D

Explanation

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When conducting a peripheral vascular assessment on the upper extremities of a client, the nurse should include which assessments? Select all that apply

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The nurse is preparing to assess the motor function of the client's trigeminal nerve. Which of the following tests would be most appropriate for the nurse to use?