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.
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Correct Answer is D
Explanation
A) Interrupt with frequent questions: While older adults may have questions, they typically do not interrupt frequently. This behavior is more indicative of anxiety or agitation rather than a cognitive change associated with aging.
B) Answer slowly and be confused: While some older adults may exhibit slower responses, confusion is not a normal cognitive change associated with aging. Confusion may suggest underlying issues such as delirium or dementia, rather than typical age-related cognitive changes.
C) Withdraw from strangers: Social withdrawal can occur in some older adults, but it is not a universal expectation. Many older adults remain engaged and sociable, and withdrawal is more commonly associated with mental health issues rather than cognitive changes.
D) Take longer to respond and react: It is common for older adults to take longer to process information and respond due to normal cognitive slowing. This may reflect changes in processing speed rather than a decline in cognitive function, and it is an expected part of aging.
Correct Answer is B
Explanation
A) Have the client smile, frown, and puff out their cheeks: This test assesses the facial nerve (cranial nerve VII), not the trigeminal nerve (cranial nerve V). While important for evaluating facial movement, it does not specifically test the motor function of the trigeminal nerve, which is responsible for mastication.
B) Palpate the masseter muscles when the client clenches their teeth: This is the correct test for assessing the motor function of the trigeminal nerve. The trigeminal nerve innervates the muscles responsible for chewing, and palpating the masseter muscles during clenching allows the nurse to evaluate muscle strength and function. It provides insight into the motor capabilities associated with this cranial nerve.
C) Assess constriction of the client's pupils with direct and indirect light: This test evaluates the function of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III). It does not assess the trigeminal nerve and is not relevant for this assessment.
D) Ask the patient to turn their head left and right with resistance: This action tests the spinal accessory nerve (cranial nerve XI), which is involved in neck movement. It does not relate to the function of the trigeminal nerve, making it an inappropriate choice for this specific assessment.