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 D

Explanation

A. Apply cornstarch to keep the skin dry. Cornstarch can cause skin irritation or promote bacterial/fungal growth, which increases the risk of breakdown rather than preventing it.

B. Reposition the client every 3 hr. Clients at risk for skin breakdown should be repositioned at least every 2 hours to relieve pressure and prevent pressure ulcers.

C. Massage bony prominences to promote circulation. Massaging bony prominences can cause tissue damage and increase the risk of pressure ulcers instead of preventing them.

D. Provide the client with a diet high in protein. Protein is essential for skin repair and maintenance, helping prevent breakdown and promote healing.

A. Kyphosis B. Scoliosis C. Lordosis D. Ankylosis

Correct Answer is A

Explanation

A. Kyphosis: Excessive forward curvature of the thoracic spine, commonly due to osteoporosis-related bone loss in older adults.

B. Scoliosis refers to a lateral curvature of the spine.

C. Lordosis: exaggerated inward curvature of the lumbar spine, often seen in pregnancy or obesity.

D. Ankylosis: abnormal stiffening or fusion of joints, unrelated to spinal curvature.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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