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) Avoid hand and foot massages: This statement may not be accurate. Gentle massages can sometimes help with circulation and comfort for individuals with peripheral neuropathy. However, caution should be exercised to avoid injury, as the sensation may be diminished.
B) Use a mirror to inspect feet daily: This is an essential teaching point. Clients with peripheral neuropathy often have decreased sensation in their feet, making it difficult to notice injuries or sores. Using a mirror allows them to check for any signs of injury or changes that could lead to complications, such as infections or ulcers.
C) Increase medication for pain as necessary: While managing pain is important, the client should be advised to consult with their healthcare provider before making any changes to their medication regimen. Self-adjusting medication could lead to unintended side effects or complications.
D) Set the water heater at 120°F: This is not advisable for someone with peripheral neuropathy, as they may not have normal temperature sensation. A lower setting is recommended to prevent burns, as the individual may not feel when the water is too hot.
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.