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. Stress incontinence. Stress incontinence occurs when intra-abdominal pressure (e.g., sneezing, coughing, laughing) causes urine leakage due to weak pelvic floor muscles or urethral sphincter dysfunction.

B. Reflex incontinence. Reflex incontinence is involuntary urination without warning due to neurological dysfunction (e.g., spinal cord injury, multiple sclerosis), which is not the case here.

C. Urge incontinence. Urge incontinence is a sudden, intense need to urinate, often caused by overactive bladder syndrome or neurological disorders. It is not associated with sneezing.

D. Overflow incontinence. Overflow incontinence occurs when the bladder fails to empty completely, leading to dribbling of urine due to urinary retention (e.g., BPH, diabetic neuropathy).

A. Having the client perform range-of-motion exercises of the arm B. Inspecting the site for reduced swelling C. Asking the client to rate the pain D. Monitoring the client's pulse rate

Correct Answer is C

Explanation

A. Having the client perform range-of-motion exercises of the arm. While movement may improve after treatment, this is not a direct measure of the effectiveness of a cold compress.

B. Inspecting the site for reduced swelling. Cold therapy reduces swelling by vasoconstriction. Swelling reduction can be an indicator of decreased inflammation but it does not provide a direct assessment of the client’s pain levels.

C. Asking the client to rate the pain. This is the most direct and reliable method to determine the effectiveness of a cold compress for pain relief.

D. Monitoring the client's pulse rate. Cold therapy does not significantly affect systemic circulation to the extent that it impacts pulse rate.

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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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Naxlex Comprehensive Predictor Exams

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