The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

Press the skin over the client's ankle bone

Lightly palpate the skin using the fingertips

Grasp a fold of skin on the client's forearm or near the sternum

Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen

Answer and Explanation

The Correct Answer is C

A. Press the skin over the client's ankle bone. – The skin over bony prominences does not provide an accurate assessment of turgor due to reduced subcutaneous tissue in elderly clients.

B. Lightly palpate the skin using the fingertips. – Light palpation assesses texture and moisture but does not evaluate skin turgor.

C. Grasp a fold of skin on the client’s forearm or near the sternum. – Skin turgor is best assessed by gently pinching the skin on the forearm or sternum. Delayed return to normal indicates dehydration or decreased skin elasticity due to aging.

D. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. – This describes petechiae, which indicate capillary fragility or bleeding disorders, not skin turgor.

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Correct Answer is D

Explanation

A. Acute disease – An acute disease has a sudden onset and short duration, but it does not necessarily involve structural changes in an organ.

B. Functional disease – A functional disease affects organ function but does not involve structural changes. Examples include irritable bowel syndrome (IBS) or migraines.

C. Chronic disease – A chronic disease persists for a long time but may or may not involve structural changes in an organ.

D. Organic disease – Organic diseases cause structural changes in an organ that lead to impaired function. Examples include cirrhosis of the liver or heart failure.

A. bruits B. crackles C. wheezing D. Turgor

Correct Answer is C

Explanation

A. Bruits – Bruits are vascular sounds caused by turbulent blood flow, typically heard over arteries.

B. Crackles – Crackles (rales) are discontinuous, crackling breath sounds caused by fluid in the alveoli, often heard in pneumonia or heart failure.

C. Wheezing – Wheezing is a high-pitched, whistling sound heard during breathing, usually caused by narrowed airways due to asthma, bronchitis, or allergic reactions.

D. Turgor – Turgor refers to skin elasticity and is used to assess hydration status, not lung sounds.

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The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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