The nurse assessing a 90-year-old patient notes that his skin is thin and turgor is non-elastic. The patient states that he always seems to be cold. What does the nurse know about these assessment findings?
The patient's integumentary system is within normal limits for his age
The patient may have a metabolic condition causing him to feel cold
The patient has abnormal thinning of skin
The patient should have elastic turgor
The Correct Answer is B
A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.
B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.
C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.
D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A) Report the abuse according to facility policy: The nurse has a legal and ethical responsibility to report suspected or disclosed abuse or neglect immediately, following the facility's protocols and state laws. This ensures that appropriate action is taken to protect the vulnerable individual and provides necessary interventions.
B) Consider a referral to social services: While this may be part of the broader care plan, the immediate priority is to report the abuse. Social services can be involved after the initial reporting to ensure that the appropriate support systems are put in place for the individual.
C) Meet with the patient's family: Meeting with the family may be relevant in some cases, but it is not the nurse's primary responsibility upon disclosure of abuse. Involving family members can sometimes complicate situations, especially if they are involved in the abuse.
D) Contact the primary care provider: While informing the primary care provider may be necessary as part of ongoing care, the urgent responsibility is to report the abuse to the proper authorities. The healthcare provider can then be informed as part of the care coordination after the initial report is made.
Correct Answer is A
Explanation
A) No discomfort: When palpating the sinuses, the expected finding is that there should be no discomfort. Healthy sinuses typically do not cause pain or tenderness during palpation, indicating that they are clear and not inflamed or infected.
B) Lumps less than 1 centimeter: While lumps may be found in various areas of the body, the presence of lumps in the sinus area during palpation is not a typical finding and may indicate an abnormality or concern that would require further evaluation.
C) Painful sensation behind the eyes: A painful sensation behind the eyes can indicate sinusitis or other sinus issues. It is not an expected finding during a normal examination of the sinuses, as healthy sinuses should not cause discomfort.
D) Heavy pressure: Heavy pressure is often a symptom associated with sinusitis or sinus congestion, but it is not an expected finding during a routine palpation of the sinuses. Healthy sinuses should not feel heavy or pressured during examination.