In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?
Assess the degree of skin elasticity.
Record palpated skin temperature.
Measure the depth of indentation.
Observe for swelling and inflammation.
The Correct Answer is A
A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bringing the client to sit at the nursing station may not address the underlying cause of the wandering behavior and could be less effective in meeting the client’s immediate needs.
B. Administering a nighttime sedative is not a suitable solution for wandering behavior, as it may lead to adverse effects and does not address the root cause of the behavior.
C. Directing the client to go back to bed may not be effective, especially if the client is disoriented or confused. The approach should involve understanding and addressing the client's needs.
D. Engaging the client to determine current needs is the best approach, as it helps to understand the cause of the wandering and address it appropriately, such as providing comfort, reassurance, or addressing a specific need.
Correct Answer is A
Explanation
A. This activity addresses both physical and social needs. It provides a gentle physical activity that can be enjoyed by people with limited mobility. It also encourages social interaction and teamwork, promoting a sense of belonging and camaraderie.
B. An open-air concert is enjoyable but may not fully engage residents in both physical and social aspects. While it offers entertainment, it lacks interactive elements that foster social engagement and physical involvement.
C. This activity requires more mobility than wheelchair-bound residents may have, especially if it involves walking on uneven terrain or sitting on the ground.
D. A tea party in the courtyard is a social activity but does not offer as much physical engagement or variety as a picnic in the park. While it is a pleasant option, it may not provide the same level of physical stimulation and change of scenery.
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