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

None

Answer and Explanation

The Correct Answer is B

Choice A rationale: Testing skin turgor on the abdomen is common in infants and young children, but in older adults, abdominal skin often loses elasticity due to aging, making it an unreliable site for assessment.

Choice B rationale: The skin over the sternum or the subclavicular area (shoulder/chest) is the most reliable site for older adults. These areas typically maintain more elastic tissue, providing a more accurate reflection of hydration.

Choice C rationale: Assessing the stomach is essentially the same as the abdomen. This site is prone to skin sagging and loss of subcutaneous fat in elderly patients, which can lead to false-positive signs of dehydration.

Choice D rationale: The skin on the neck is thin and highly susceptible to wrinkles and sun damage. Lifting the skin here in an older adult will often show "tenting" even if the patient is well-hydrated.

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Correct Answer is D

Explanation

Choice A reason:

Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.

Choice B reason:

Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.

Choice Creason:

Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.

Choice D reason:

The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

A. Compare the clients current weight with preprocedure weight B. Examine for leakage at the site of the procedure. C. Check the client’s serum albumin levels D. Confirm that the client is able to urinate

Correct Answer is A

Explanation

The correct answer is choice A. Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.

Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.

Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.

Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.

Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.

Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.

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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?

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