When assessing the skin of an elderly client, the nurse notes tenting. The nurse understands what about this assessment?
This would indicate pitting edema
This may indicate dehydration, but might not be reliable in an older adult
This means the client is well hydrated
This indicates peripheral neuropathy
The Correct Answer is B
A) This would indicate pitting edema: Tenting is not indicative of pitting edema, which is characterized by a depression left in the skin after pressure is applied. Tenting specifically refers to the skin's elasticity and is assessed by pinching the skin, observing how quickly it returns to its normal position.
B) This may indicate dehydration, but might not be reliable in an older adult: Tenting is often a sign of dehydration, as it reflects decreased skin elasticity. However, in elderly individuals, skin changes due to aging (like reduced elasticity and moisture) may make this assessment less reliable. Factors such as medications, health status, and overall skin integrity can also influence this observation, making it necessary to consider other indicators of hydration.
C) This means the client is well hydrated: Tenting does not indicate adequate hydration. In fact, it typically suggests the opposite, as well-hydrated skin should return to normal quickly after being pinched.
D) This indicates peripheral neuropathy: While peripheral neuropathy can affect skin and tissue integrity, tenting specifically relates to skin turgor and elasticity rather than nerve function. Tenting is not a direct indicator of neuropathy; other assessments would be needed to evaluate nerve health.
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Correct Answer is B
Explanation
A) "Attempt to rotate your head in a circular manner": This instruction is focused on rotation rather than lateral flexion. While rotation assesses different neck movements, it does not specifically evaluate lateral flexion.
B) "Lean your head to the side and attempt to touch your ear to your shoulder": This instruction directly assesses lateral flexion of the neck. It encourages the client to bend their head to the side, effectively demonstrating the range of motion in that direction.
C) "Attempt to raise your shoulders up toward your ears": This instruction assesses shoulder elevation and shrugging rather than lateral flexion of the neck. It does not provide information about the lateral movement of the head.
D) "Tilt your head back and look at the ceiling": This instruction assesses extension of the neck rather than lateral flexion. It evaluates the ability to move the head backward.
Correct Answer is ["A","C","D"]
Explanation
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.