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
Stomach
Neck
The Correct Answer is D
Choice A reason
Abdomen area is not appropriate: Assessing skin turgor on the abdomen is not commonly performed. The abdomen may not be the most accurate site for assessing skin turgor, especially in older adults, as it can be influenced by factors such as body fat distribution.
Choice B reason:
Shoulder are is not appropriate: The shoulder is not a typical site for assessing skin turgor. It is generally not used for this purpose, as it may not provide reliable results
Choice C reason:
Stomach is not the correct answer.: Assessing skin turgor on the stomach is also not commonly performed. The abdomen or stomach may not be the most accurate site for assessing skin turgor, especially in older adults.
Choice D reason
When assessing skin turgor in an older adult client, the nurse should lift the skin on the neck to evaluate its elasticity and hydration status. Skin turgor is a measure of skin's elasticity and is commonly used as an indicator of hydration in both adults and older adults.
To assess skin turgor, the nurse will gently pinch a small amount of skin on the back of the client's hand or the front of the chest (sternum). However, since the options listed do not include these areas, the closest alternative for an older adult would be the neck.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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The correct answer is choice c. Contractions.
Choice A rationale:
Epigastric pain is not a common complication following an amniocentesis. It is more often associated with conditions like preeclampsia or gastrointestinal issues.
Choice B rationale:
Hypertension is not directly related to amniocentesis. It is more commonly associated with conditions like preeclampsia or chronic hypertension in pregnancy.
Choice C rationale:
Contractions are a significant complication to monitor for after an amniocentesis, especially at 33 weeks of gestation. The procedure can sometimes induce preterm labor.
Choice D rationale:
Vomiting is not a typical complication following an amniocentesis. It may occur due to other unrelated reasons but is not directly linked to the procedure.
Correct Answer is B
Explanation
The correct answer is choice b. "I can start the medication 30 minutes earlier."Choice A rationale: This is an inappropriate response, as the nurse should not adjust the time and schedule for the administration of alteplase recombinant, which is a time-sensitive medication used to treat a thrombus in the coronary artery. The administration of this medication must be done within a specific time frame to be effective.Choice B rationale: This is the correct answer. Alteplase recombinant is a thrombolytic medication used to dissolve blood clots in the coronary artery. It is a time-sensitive medication, and it is crucial to administer it as soon as possible to minimize the damage to the heart muscle. Starting the medication 30 minutes earlier is an appropriate action to include in the plan of care, as it can help ensure the medication is administered within the recommended time frame.Choice C rationale: This is an inappropriate response. Alteplase recombinant should be administered within a specific time frame, typically within 3 to 4.5 hours of the onset of symptoms. Waiting up to 2 hours after the usual schedule time to give the medication would be outside the recommended time frame and could potentially reduce the effectiveness of the treatment.Choice D rationale: This is an inappropriate response. Alteplase recombinant should be infused at a specific rate, as recommended by the manufacturer or healthcare provider. Infusing the medication at a faster rate could increase the risk of adverse effects and should not be included in the plan of care without specific instructions from the healthcare provider.
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