During your physical examination of a 29-year-old professional volley ball player who recently completed a beach tournament, you gently pinch the skin on the chest area. The skin remains in a "tent" shape and slowly returns to its normal position. This is a sign of

Dehydration

Hypervolemia

Properly Hydrated

Infection

Answer and Explanation

The Correct Answer is A

A) Dehydration:

When the skin remains tented and returns to its normal position slowly after being pinched, it indicates decreased skin turgor, which is a clinical sign of dehydration. Dehydration can occur due to fluid loss from sweating during vigorous physical activity like a beach tournament.

B) Hypervolemia:

Hypervolemia refers to excess fluid volume in the body, which would typically manifest with signs such as peripheral edema or jugular vein distention rather than decreased skin turgor.

C) Properly Hydrated:

Properly hydrated individuals would have normal skin turgor, where the skin returns promptly to its normal position after being pinched.

D) Infection:

Skin tenting is not a specific sign of infection. Infection would typically present with localized signs such as redness, warmth, swelling, and possibly systemic signs like fever.

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Correct Answer is C

Explanation

A. Measure nerve function in the fingers:

Measuring nerve function typically involves different assessments, such as checking sensation or performing nerve conduction studies. The action in the image is not indicative of a nerve function test.

B. Monitor oxygen status:

Monitoring oxygen status is usually done with a pulse oximeter, which is placed on the finger but does not involve the manual action shown in the image. The image depicts a manual technique, not a pulse oximetry procedure.

C. Determine capillary refill:

The action shown in the image is a technique used to determine capillary refill time. The nurse presses on the nail bed until it blanches and then releases it to see how quickly the color returns. This assesses peripheral perfusion and can indicate circulatory status.

D. Assess finger range of motion:

Assessing finger range of motion involves moving the fingers through their full range of motion, such as flexing, extending, abducting, and adducting them. The action in the image does not reflect these movements and is more indicative of assessing capillary refill.

A. "Let's discuss your risk factors for heart disease." B. "We should review the amount of protein in your diet." C. "Waist circumference can vary over the course of the day." D. "You probably have a vitamin deficiency."

Correct Answer is A

Explanation

A) "Let's discuss your risk factors for heart disease.":

A waist circumference of 43 inches (109 cm) in a male is considered elevated and indicates central obesity, which is a significant risk factor for cardiovascular diseases, including heart disease, hypertension, and type 2 diabetes. Addressing this finding by discussing risk factors for heart disease is appropriate and necessary for preventive healthcare.

B) "We should review the amount of protein in your diet.":

While diet is important, protein intake is not directly related to waist circumference. The primary concern with a large waist circumference is the associated risk of metabolic and cardiovascular conditions, rather than specific macronutrient consumption.

C) "Waist circumference can vary over the course of the day.":

Though there can be minor variations in waist circumference throughout the day due to factors like fluid retention or meals, a measurement of 43 inches is significantly above the threshold indicating central obesity. This warrants a discussion about health risks rather than focusing on daily fluctuations.

D) "You probably have a vitamin deficiency.":

Vitamin deficiencies are not directly indicated by waist circumference measurements. This statement is not appropriate given the finding, as the primary concern with a large waist circumference is its association with increased risk of chronic diseases rather than nutrient deficiencies.

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During your physical examination of a 29-year-old professional volley ball player who recently completed a beach tournament, you gently pinch the skin on the chest area. The skin remains in a "tent" shape and slowly returns to its normal position. This is a sign of

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment the nurse performs the action shown in this image. What is the purpose of this action?

Correct Answer is C

Explanation

The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding?

Correct Answer is A

Explanation

At which location would a nurse palpate a client's occipital lymph nodes?

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

Which nutritional data obtained from a client needs MOST validation by a nurse?

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

Which of the following best describes Hyperopia?

A nurse assesses a 60kg adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client? Round to the whole number.

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

The nurse asks the client to perform the action pictured. What is the nurse assessing?