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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View Related questions
Correct Answer is A
Explanation
A) Symmetry: During a breast inspection, the nurse should assess for symmetry between the two breasts. It is normal for there to be some slight differences, but significant asymmetry can indicate underlying issues that may need further evaluation.
B) Hard nodules: While the presence of hard nodules would be a significant finding, this would typically be assessed through palpation rather than inspection. The initial visual assessment focuses on appearance, shape, and symmetry.
C) Skin texture: Skin texture may be observed during inspection, but it is not a primary finding that stands out as a key assessment element. It can be noted as part of a comprehensive evaluation but is not the main focus.
D) Tenderness: Tenderness is a subjective assessment that is evaluated through palpation and client reporting, rather than through inspection. The nurse cannot document tenderness solely based on visual assessment.
Correct Answer is C
Explanation
A) Talking in a loud voice: While this may indicate some level of distress or confusion, it does not necessarily signal a specific neurological deficit. Clients may raise their voice for various reasons unrelated to neurological issues.
B) Grimacing with movement: This could suggest discomfort or pain but is not an explicit indicator of neurological impairment. Grimacing can occur for many reasons, including musculoskeletal issues or emotional responses, and does not specifically necessitate a focused neurological assessment.
C) Asymmetry of the client's smile: This finding is significant and raises concerns about potential neurological issues, such as a stroke or Bell's palsy. Facial asymmetry may indicate weakness or dysfunction in the cranial nerves responsible for facial movement, warranting a more thorough neurological examination to assess for underlying causes.
D) Inability to follow directions: While this may point to confusion or cognitive impairment, it is a more general indicator and could result from various factors, including anxiety or lack of understanding. It does not specifically highlight a localized neurological deficit as clearly as facial asymmetry does.