A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?
Abdomen
Shoulder
Neck
Sternum
The Correct Answer is D
Rationale:
A. Abdomen: The abdominal skin may be loose due to age-related changes, weight fluctuations, or prior pregnancies, making it less reliable for assessing dehydration in older adults. Lifting skin here may give a false impression of skin turgor.
B. Shoulder: Skin over the shoulder can be affected by aging, sun exposure, or decreased subcutaneous tissue, which can distort the assessment of hydration status. It is not the preferred site for older adults.
C. Neck: The skin of the neck is thin and may show wrinkles or sagging unrelated to hydration. Assessing turgor here is less accurate in older clients and may overestimate skin elasticity changes due to aging.
D. Sternum: The skin over the sternum is relatively less affected by age-related changes and provides a more reliable site for assessing turgor in older adults. Lifting this area allows the nurse to evaluate hydration status more accurately without interference from natural skin laxity elsewhere.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Strabismus: Strabismus, or misalignment of the eyes, is not a known adverse effect of timolol. Timolol primarily affects intraocular pressure and systemic cardiovascular parameters rather than eye muscle alignment.
B. Bradycardia: Timolol is a nonselective beta-adrenergic blocker that can be absorbed systemically even when administered as eye drops. One potential systemic adverse effect is bradycardia, as the medication can reduce heart rate and cardiac output, particularly in clients with preexisting heart conditions.
C. Conjunctivitis: While eye irritation or mild stinging can occur with timolol, conjunctivitis is not a typical adverse effect. Instructing clients to monitor for more common ocular side effects, such as burning or discomfort, is appropriate.
D. Hyperglycemia: Timolol does not typically cause hyperglycemia. Beta-blockers can sometimes mask hypoglycemia symptoms in diabetic clients but are not associated with raising blood glucose levels directly.
Correct Answer is C
Explanation
Rationale:
A. Increase the rate of the oxytocin infusion: Increasing oxytocin would intensify uterine contractions, which can worsen uteroplacental insufficiency and exacerbate late decelerations. This action is unsafe and contraindicated when late decelerations are present.
B. Administer dinoprostone transvaginally: Dinoprostone is used to ripen the cervix or induce labor, not to correct fetal distress caused by uteroplacental insufficiency. Administering it in this scenario would not address the underlying problem and could increase fetal risk.
C. Place the client in a lateral position: Lateral positioning improves uteroplacental blood flow and oxygen delivery to the fetus, which can reduce late decelerations. It is an immediate, safe, and effective nursing intervention to relieve fetal stress caused by decreased placental perfusion.
D. Assist the client to empty their bladder: While bladder distention can affect uterine contractions and comfort, it does not directly address late decelerations. Emptying the bladder may be beneficial for other reasons, but repositioning the client takes priority in improving fetal oxygenation.
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