A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?
Examine the back before the general inspection of the skin.
Note dry, flaky skin as an expected finding.
Use a penlight to examine the back in greater detail.
Pinch up a fold of skin to check for turgor.
The Correct Answer is D
A. Examine the back before the general inspection of the skin: Skin assessment should follow a general inspection.
B. Note dry, flaky skin as an expected finding: While common in older adults, it may indicate dehydration or dermatologic conditions.
C. Use a penlight to examine the back in greater detail: Penlights are typically used for darker areas (e.g., mouth, wounds), not flaky skin.
D. Pinch up a fold of skin to check for turgor: Assesses hydration status, which is important since dehydration contributes to dry, flaky skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Examine the back before the general inspection of the skin: Skin assessment should follow a general inspection.
B. Note dry, flaky skin as an expected finding: While common in older adults, it may indicate dehydration or dermatologic conditions.
C. Use a penlight to examine the back in greater detail: Penlights are typically used for darker areas (e.g., mouth, wounds), not flaky skin.
D. Pinch up a fold of skin to check for turgor: Assesses hydration status, which is important since dehydration contributes to dry, flaky skin.
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