A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

Press the skin over the client's ankle bone.

Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen.

Lightly palpate the skin using the fingertips.

Grasp a fold of skin on the client's forearm or near the sternum.

Answer and Explanation

The Correct Answer is D

A. Press the skin over the client's ankle bone. Skin over the bony prominences is not ideal for assessing turgor, as it may not accurately reflect dehydration.

B. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. This describes petechiae, which is a sign of bleeding disorders, not hydration status.

C. Lightly palpate the skin using the fingertips. Palpation does not assess elasticity.

D. Grasp a fold of skin on the client's forearm or near the sternum. The best way to check for dehydration is by pinching the skin on the sternum or forearm and observing how quickly it returns to normal.

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Correct Answer is A

Explanation

A. "How do you handle stress?" While stress may influence some skin conditions (e.g., psoriasis, eczema), this question is not directly related to a focused skin assessment and may be too vague or irrelevant.

B. "Does your skin condition keep you awake at night?" Skin conditions such as eczema or urticaria can cause pruritus, leading to sleep disturbances. This is a relevant question.

C. "How does your skin condition make you feel about yourself?" Skin conditions can affect body image and self-esteem, making this an important question for psychosocial assessment.

D. "Have you had any changes in your diet?" Certain food allergies or deficiencies can trigger dermatologic conditions (e.g., celiac disease, atopic dermatitis), making this question appropriate.

A. Paralytic ileus B. Incisional infection C. Fecal impaction D. Health care-associated Clostridium difficile

Correct Answer is A

Explanation

A. Paralytic ileus. A postoperative complication in which the intestines stop moving due to anesthesia or surgical trauma. Absence of bowel sounds, abdominal distention, and no flatus are key signs.

B. Incisional infection. An incisional infection would present with redness, warmth, drainage, and fever, but not absence of bowel sounds.

C. Fecal impaction. Fecal impaction causes stool retention, and the client might still pass small amounts of liquid stool, whereas paralytic ileus presents with no bowel movement at all.

D. Health care-associated Clostridium difficile. C. difficile infection presents with frequent watery diarrhea, not absent bowel sounds.

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A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

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