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The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.

Texture

Tachypnea

Turgor

Temperature

Tympany

Question Solution

Correct Answer : A,C,D

A) Texture: Assessing the texture of the skin is an important part of a comprehensive skin assessment. It provides insights into the health and hydration status of the skin. Normal skin texture should feel smooth and even, while changes can indicate issues such as dryness or conditions like eczema or psoriasis.

B) Tachypnea: This term refers to an increased respiratory rate and is not a characteristic assessed in the skin. While it can indicate a physiological response to various conditions, it does not relate to skin health or characteristics and therefore is not relevant in this context.

C) Turgor: Skin turgor refers to the elasticity and hydration status of the skin, which can be assessed by pinching the skin. Proper turgor indicates adequate hydration, while decreased turgor can signal dehydration or other health issues. This is an essential component of skin assessment.

D) Temperature: Assessing the temperature of the skin can provide information about circulation and potential inflammation or infection. Normal skin temperature should feel warm and consistent, while variations can suggest underlying conditions such as fever or shock.

E) Tympany: Tympany is a term used in percussion assessments of the abdomen and is not applicable to skin assessment. It refers to a hollow sound produced by tapping on a body surface and does not pertain to skin characteristics.

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A. Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2. B. Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2. C. Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal. D. Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal.

Correct Answer is B

Explanation

A) Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2: While this option describes the left extremity and includes some relevant details, it inaccurately uses "normal pitting edema" without specifying the degree of edema clearly. Additionally, it lists the posterior tibial pulse instead of the popliteal, which is more appropriate given the anatomical location.

B) Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2: This documentation accurately describes the left lower extremity, specifies the degree of edema as "+2," and correctly identifies the relevant pulses as femoral, popliteal, and dorsalis pedis. This terminology is clear and concise, providing a comprehensive assessment of the vascular status.

C) Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal: This option incorrectly reports the degree of edema as "+4," which indicates severe swelling, not matching the original assessment of "mild edema." It also incorrectly lists the posterior tibial pulse, which should be popliteal.

D) Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal: The term "normal cool temperature" is confusing and not standard terminology. Additionally, "slight swelling" lacks specificity regarding the degree of edema, which is important for a clinical assessment. Furthermore, it inaccurately refers to the posterior tibial pulse instead of the popliteal.

A. Increased muscle weakness B. Pronounced muscle atrophy C. Diminished visual acuity D. Impaired cognitive reasoning

Correct Answer is A

Explanation

A) Increased muscle weakness: Guillain-Barré syndrome is characterized by the rapid onset of muscle weakness, which typically starts in the lower extremities and ascends. The nurse would expect to find varying degrees of muscle weakness as a hallmark symptom, which may progress to involve the upper limbs and respiratory muscles.

B) Pronounced muscle atrophy: While muscle weakness is a significant feature of Guillain-Barré syndrome, pronounced muscle atrophy is not typically seen immediately. Muscle atrophy may occur over time due to disuse but is not a direct initial finding upon assessment.

C) Diminished visual acuity: Visual acuity may not be directly affected in Guillain-Barré syndrome. While some patients may experience ocular symptoms, diminished visual acuity is not a primary feature of the syndrome and would not be expected as a common assessment finding.

D) Impaired cognitive reasoning: Guillain-Barré syndrome primarily affects the peripheral nervous system and does not usually impact cognitive function. Patients typically maintain full cognitive abilities, so the nurse should not anticipate findings

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The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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Take full exam for free The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.

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A student nurse documents the following: Lower left leg cool, mild edema, with dorsalis pedis, posterior knee and femoral pulse normal. How should this documentation be charted to communicate the assessment using appropriate medical terminology?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.