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

Answer and Explanation

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.

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Correct Answer is ["B","D","E","H"]

Explanation

• B: Heart rate 99/min. This is a finding that requires immediate follow-up because it is above the normal range for a 16-year-old client, which is 60 to 100 beats per minute. A high heart rate could indicate anxiety, stress, pain, infection or other conditions that need to be addressed.

• D: Client experiences nightmares. This is a finding that requires immediate follow-up because it could indicate post-traumatic stress disorder (PTSD), which is a mental health condition that can develop after witnessing or experiencing a traumatic event. PTSD can cause distressing symptoms such as nightmares, flashbacks, intrusive thoughts, avoidance, negative mood and hyperarousal. PTSD can interfere with the client’s daily functioning and well-being and requires professional treatment.

• E: Witnessing their family’s death. This is a finding that requires immediate follow-up because it is the most likely cause of the client’s PTSD symptoms and emotional distress. Witnessing the death of one’s family members is a devastating and traumatic experience that can have lasting effects on the client’s mental health. The client may benefit from grief counseling, trauma-focused therapy, medication or other interventions to help them cope with their loss and trauma.

• H: Smoking marijuana to clear their mind. This is a finding that requires immediate follow-up because it indicates that the client is using an illicit substance to self-medicate their emotional pain. Smoking marijuana can have negative effects on the client’s physical and mental health, such as impairing their memory, cognition, judgment, coordination and motivation. It can also increase the risk of addiction, dependence and withdrawal symptoms. The client may need substance abuse counseling, education, referral or other services to help them quit smoking marijuana and find healthier ways to cope with their feelings.
The other findings do not require immediate follow-up for the following reasons:

• A: BP 122/80 mmHg. This is not a finding that requires immediate follow-up because it is within the normal range for a 16-year-old client, which is 110 to 120/70 to 80 mmHg. A normal blood pressure indicates that the client’s cardiovascular system is functioning well and there are no signs of hypertension or hypotension.

• C: Startles easy during thunderstorm. This is not a finding that requires immediate follow-up because it is a normal reaction to a loud noise or a frightening stimulus. The client admits that they have always been afraid of thunderstorms, which suggests that this is not a new or unusual behavior for them. However, the nurse may want to monitor the client’s anxiety level and provide reassurance and comfort during thunderstorms.

• F: Caregiver reporting client acting differently than usual. This is not a finding that requires immediate follow-up because it is a vague and subjective statement that does not specify how the client is acting differently or what changes have occurred in their behavior. The nurse may want to ask the caregiver for more details and examples of how the client has changed since the traumatic event and assess whether these changes are normal or concerning.

• G: Attends school regularly. This is not a finding that requires immediate follow-up because it indicates that the client is maintaining their academic performance and social interactions despite their trauma and grief. Attending school regularly can provide the client with a sense of routine, structure, support and achievement that can help them cope with their situation. However, the nurse may want to check with the client’s teachers and peers to see if they have noticed any changes in the client’s mood, behavior or participation at school.

A. Acrocyanosis B. Bradycardia C. Bulging fontanels D. Hypertonicity

Correct Answer is D

Explanation

Hypertonicity is a sign of increased muscle tone and stiffness, which can indicate that the newborn is experiencing withdrawal from methadone exposure in utero. Methadone is an opioid medication that can cross the placenta and cause neonatal abstinence syndrome (NAS) in the newborn.

Choice A, acrocyanosis, is wrong because it is a normal finding in newborns.

Acrocyanosis is a bluish discoloration of the hands and feet due to immature peripheral circulation. It usually resolves within the first 24 to 48 hours of life.

Choice B, bradycardia, is wrong because it is not a typical sign of withdrawal.

Bradycardia is a slow heart rate, usually less than 100 beats per minute in newborns. It can be caused by hypoxia, hypothermia, hypoglycemia, or vagal stimulation.

Choice C, bulging fontanels, is wrong because it is a sign of increased intracranial pressure, not withdrawal. Bulging fontanels can be caused by meningitis, hydrocephalus, or hemorrhage.

Normal ranges for newborn vital signs are as follows:

Heart rate: 120 to 160 beats per minute
Respiratory rate: 30 to 60 breaths per minute
Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic

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A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","E","H"]

Explanation

A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?

Correct Answer is D

Explanation

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