The nurse is assessing an elderly patient’s skin turgor and notes that it is poor.
The nurse understands that this finding may be due to which of the following reasons?
Dehydration
Malnutrition
Loss of subcutaneous fat.
Reduced collagen fibers.
The Correct Answer is A
The correct answer is A.
Dehydration.
Poor skin turgor means that the skin takes longer to return to its normal position after being pinched or pulled.
This is a sign of dehydration, which means the body does not have enough fluid.
Dehydration can be caused by not drinking enough water, vomiting, diarrhea, fever, diabetes, or other conditions that affect fluid balance.
Choice B is wrong because malnutrition does not directly affect skin turgor.
Malnutrition means the body does not get enough nutrients from food.
This can cause various problems, such as weight loss, muscle wasting, poor wound healing, and infections.
However, malnutrition does not cause the skin to lose its elasticity.
Choice C is wrong because loss of subcutaneous fat does not cause poor skin turgor.
Subcutaneous fat is the layer of fat under the skin that helps insulate the body and store energy.
As people age, they tend to lose some subcutaneous fat, especially in the face and hands.
This can make the skin look thinner and more wrinkled, but it does not affect how quickly the skin snaps back after being pinched.
Choice D is wrong because reduced collagen fibers do not cause poor skin turgor.
Collagen is a protein that gives the skin its strength and structure.
As people age, they produce less collagen, which can make the skin sag and lose firmness.
However, collagen does not affect the skin’s ability to retain water and return to its normal shape after being stretched.
Normal ranges for skin turgor vary depending on the age and location of the skin.
In general, healthy skin should return to its normal position within 2 seconds after being pinched.
In children and young adults, skin turgor can be tested on the abdomen or forearm. In elderly people, skin turgor can be tested on the clavicle (collar bone), sternum (breastbone), forehead, or inner thigh. These sites are less affected by skin wrinkling and aging.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
The correct answer isA, D, and E.
Here is why:.
A. Elevated white blood cell count.
This is a sign of infection and inflammation in the body, which can be caused by a UTI.An elevated white blood cell count can also indicate a complication of UTI such as pyelonephritis (kidney infection) or sepsis (blood infection).
D. Altered mental status.
This is a common symptom of UTI in older adults, especially those with dementia or other cognitive impairments.UTIs can cause confusion, agitation, delirium, or behavioral changes in the elderly due to the effects of infection and inflammation on the brain.
E. Positive urine culture.
This is the definitive test to diagnose a UTI, as it identifies the type and number of bacteria present in the urine.A positive urine culture confirms the presence of a UTI and guides the appropriate antimicrobial treatment.
The other choices are wrong because:.
•.
B. Decreased serum creatinine level.
This is not a sign of UTI or its complications.
Serum creatinine is a measure of kidney function, and it usually increases when the kidneys are damaged or impaired.A decreased serum creatinine level may indicate other conditions such as liver disease, muscle wasting, or malnutrition.
•.
C. Increased urine specific gravity.
This is not a sign of UTI or its complications.
Urine specific gravity is a measure of urine concentration, and it usually increases when the body is dehydrated or has high levels of solutes in the urine.An increased urine specific gravity may indicate other conditions such as diabetes mellitus, heart failure, or dehydration.
Normal ranges for some of these tests are:.
• White blood cell count: 4,000 to 11,000 cells per microliter (mcL) of blood.
• Serum creatinine: 0.6 to 1.2 milligrams per deciliter (mg/dL) for men and 0.5 to 1.1 mg/dL for women.
• Urine specific gravity: 1.005 to 1.030.
Correct Answer is B
Explanation
The correct answer isB.
Loss of muscle mass and strength.Sarcopenia is a condition that affects older adults and causes a progressive decline in skeletal muscle mass, strength, and function.This can lead to an increased risk of falls, fractures, disability, and mortality.
Choice A is wrong because the loss of bone mass and strength is calledosteoporosis, not sarcopenia.Osteoporosis is a condition that affects the density and quality of bones, making them more prone to fracture.
Choice C is wrong because loss of joint flexibility and range of motion is calledarthritis, not sarcopenia.
Arthritis is a term that refers to inflammation of the joints, which can cause pain, stiffness, swelling, and reduced mobility.
Choice D is wrong because loss of skin elasticity and moisture is calledskin aging, not sarcopenia.
Skin aging is a process that involves changes in the structure and function of the skin, such as wrinkles, sagging, dryness, and decreased wound healing.
Normal ranges for muscle mass and strength vary depending on age, sex, body size, and physical activity level.However, some general indicators of sarcopenia include:.
• A muscle mass index (muscle mass divided by height squared) below 7.26 kg/m2 for men and 5.45 kg/m2 for women.
• A handgrip strength below 30 kg for men and 20 kg for women.
• A gait speed below 0.8 m/s for both sexes.
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