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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Request a prescription for an indwelling urinary catheter. Long-term catheter use increases the risk of infection and is not the first-line intervention for functional incontinence.

B. Remind the client to tell the nurse when he has to urinate. Clients with dementia often have difficulty recognizing or communicating the need to urinate.

C. Take the client to the bathroom on an every-2-hr schedule. Scheduled toileting helps manage incontinence by anticipating the client’s needs and reducing accidents.

D. Use adult diapers to prevent frequent clothing changes. This does not address the underlying issue and may contribute to skin breakdown and decreased dignity.

A. Press the skin over the client's ankle bone. B. Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen. C. Lightly palpate the skin using the fingertips. D. Grasp a fold of skin on the client's forearm or near the sternum.

Correct Answer is D

Explanation

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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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?

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Naxlex Comprehensive Predictor Exams

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