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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

Answer and Explanation

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.

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A. Low self-esteem B. His complaints of numbness in his hands C. Risk for injury D. Persistent pain

Correct Answer is C

Explanation

A) Low self-esteem: While low self-esteem can develop as a result of limitations in physical abilities, it is not the most immediate concern in this scenario. Addressing the patient's functional capabilities and safety takes precedence.

B) His complaints of numbness in his hands: Numbness is a significant symptom of carpal tunnel syndrome, but the immediate priority is to ensure the patient can safely perform tasks. While it is important to address his symptoms, managing the risk associated with his condition is more critical.

C) Risk for injury: This is the most pressing concern for the patient. Given his difficulty holding tools, there is a heightened risk of accidents or injuries while working. Prioritizing safety measures is essential to prevent harm and ensure he can continue his work safely.

D) Persistent pain: While pain management is important, the focus should be on the immediate risk of injury related to the patient's inability to hold tools securely. Addressing safety concerns takes precedence over managing pain at this point.

A. Alert and oriented B. Cyanosis C. Anxiety and restlessness D. Oxygen saturation 96% E. Capillary refill 5 seconds

Correct Answer is ["B","C","E"]

Explanation

A) Alert and oriented: Being alert and oriented typically indicates adequate oxygenation, not hypoxia. Patients experiencing hypoxia are more likely to show signs of confusion or altered mental status rather than clarity.

B) Cyanosis: Cyanosis is a classic sign of hypoxia, presenting as a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is a significant indicator of inadequate oxygenation.

C) Anxiety and restlessness: These symptoms are common responses to hypoxia as the body attempts to compensate for insufficient oxygen. Patients may feel anxious or restless as they struggle to breathe or feel a sense of impending doom.

D) Oxygen saturation 96%: An oxygen saturation level of 96% is generally considered normal and indicates adequate oxygenation. Therefore, this finding does not suggest hypoxia.

E) Capillary refill 5 seconds: A prolonged capillary refill time can indicate poor perfusion and potential hypoxia. Inadequate blood flow can lead to reduced oxygen delivery to tissues, making this a relevant sign of hypoxia

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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?

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Correct Answer is C

Explanation

Correct Answer is ["B","C","E"]

Explanation

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Take full exam for free 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?

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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?