The patient who is confined to bed in the supine position has gained 5 lbs. in the last 48 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema?
Foot
Forehead
Ankle
Chest
Sacrum
The Correct Answer is E
Dependent edema refers to the accumulation of fluid in the dependent parts of the body, which are areas that are most affected by gravity when a person is in a supine or sitting position for an extended period. The sacrum, which is the triangular bone at the base of the spine, is one such dependent area. It is prone to developing edema when there is increased fluid retention in the body, as seen in the patient's weight gain.
To assess for dependent edema accurately, the nurse can gently press the skin over the sacral area with their fingers and observe the skin turgor or the return of the skin to its normal position after releasing the pressure. If there is edema, the skin may have reduced elasticity and take longer to return to its normal position (poor skin turgor).
While edema can occur in other dependent areas such as the feet, ankles, and lower legs, assessing skin turgor in these areas may not provide an accurate determination of dependent edema as they are located further away from the sacrum and may be influenced by other factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The pH value of 7.5 indicates alkalosis, as it is above the normal range of 7.35-7.45. The elevated bicarbonate (HCO3-) level of 34 mmol/L suggests metabolic alkalosis, as it is higher than the normal range of 22-28 mmol/L. The PaCO2 level of 40 mm Hg falls within the normal range of 35-45 mm Hg.
In this case, the primary disturbance is metabolic alkalosis, which is likely caused by the persistent vomiting leading to excessive loss of gastric acid (hydrogen ions) and chloride ions from the stomach. This loss of acid and chloride results in an imbalance of electrolytes and an increase in bicarbonate levels, leading to metabolic alkalosis.
Since there is no significant deviation from the normal range in the PaCO2 level, the respiratory system has not effectively compensated for the metabolic alkalosis. Therefore, it is considered uncompensated.
Correct Answer is ["A","C","D","F"]
Explanation
Muscle rigidity is a hallmark sign of malignant hyperthermia. It commonly affects the muscles of the jaw and upper chest.
Malignant hyperthermia can lead to rapid and shallow breathing, resulting in tachypnea. Malignant hyperthermia is characterized by a significant increase in body temperature, often exceeding 38.8°C (101.8°F).
Malignant hyperthermia can cause irregular heart rhythms or dysrhythmias, including tachycardia or arrhythmias.
The manifestations of hypertension and skin mottling are not typically associated with malignant hyperthermia. Hypertension (high blood pressure) is more commonly seen in conditions such as hypertensive emergencies or certain cardiovascular disorders. Skin mottling, which refers to irregular or patchy skin coloration, is not a specific manifestation of malignant hyperthermia.
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