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
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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Correct Answer is C
Explanation
A) Third left ICS: The third left intercostal space (ICS) is typically associated with the auscultation of the pulmonic valve rather than the tricuspid valve. While it is in the vicinity of the heart, it is not the correct location for assessing the tricuspid area.
B) Second right ICS: The second right intercostal space is where the aortic valve is best heard. This location is important for assessing blood flow through the aorta, but it is not relevant for the tricuspid valve auscultation.
C) Fourth left ICS: The tricuspid valve is best auscultated at the fourth left intercostal space along the left sternal border. This area allows for optimal listening to the sounds produced by the tricuspid valve, providing important information about right heart function.
D) Second left ICS: The second left intercostal space is the auscultation point for the pulmonic valve, not the tricuspid valve. While this area is critical for assessing the heart, it does not correspond to the location for the tricuspid valve.
Correct Answer is C
Explanation
A) Dizziness: While the term "dizziness" can describe a range of sensations, it is more general and does not specifically capture the experience of the patient feeling that the room is spinning. Dizziness can include feelings of lightheadedness or imbalance, which are not the primary symptoms the patient is describing.
B) Tinnitus: Tinnitus refers to the perception of sound, such as ringing or buzzing, in the absence of an external source. This term does not relate to the patient's symptoms of spinning sensations and nausea, making it irrelevant in this context.
C) Vertigo: This term accurately describes the sensation of spinning or movement, often associated with inner ear disturbances. The patient's description aligns with vertigo, as it reflects the specific experience of feeling as though the environment is moving, which can indeed lead to nausea.
D) Otalgia: Otalgia refers to ear pain and is not applicable to the symptoms the patient describes. Since the patient is focusing on a spinning sensation and associated nausea, this term does not relate to the presenting issue.