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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Explanation
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B) "All women should have a breast screening with an MRI beginning at age 40": This statement is misleading, as the American Cancer Society does not recommend routine MRI screenings for all women. MRI is typically reserved for women at high risk for breast cancer. The standard guideline includes annual mammograms starting at age 40, but not MRI for all.
C) "Mammograms do not help with detecting breast cancer until after age 54": This statement is incorrect. Mammograms are effective in detecting breast cancer well before age 54, and the American Cancer Society recommends that women start getting annual mammograms at age 40. Early detection through regular screenings is critical for improving outcomes.
D) "Mammograms are only indicated if there is a strong family history": This statement is also inaccurate. While family history can increase the risk for breast cancer and may influence screening frequency, all women are encouraged to have regular mammograms starting at age 40, regardless of family history. This guideline aims to catch potential cancers early in all women.
Correct Answer is ["A","C","D","E"]
Explanation
A) Impact on ADLs: Understanding how pain affects a client's activities of daily living (ADLs) is crucial for assessing the overall impact of the pain on their life. It provides insight into the functional limitations caused by the pain and helps guide treatment planning.
B) Family medical history: While family medical history can provide context for certain conditions, it is not an essential component of a focused pain assessment. The immediate concerns are more directly related to the client's current pain experience rather than their family's medical background.
C) Pain intensity rating: Assessing the intensity of pain is a fundamental aspect of pain assessment. Using scales (e.g., 0-10) allows the nurse to quantify the pain, monitor changes over time, and evaluate the effectiveness of interventions.
D) Characteristics of the pain: Understanding the characteristics of the pain—such as its quality (sharp, dull, throbbing) and location—is essential for determining its cause and guiding appropriate treatment strategies.
E) Aggravating factors: Identifying what exacerbates the pain is critical for understanding its nature and developing effective management strategies. Knowing which activities or positions worsen the pain can help in creating a comprehensive care plan tailored to the client's needs.