The nurse is assessing skin turgor. Which technique will the nurse use?
a. Press lightly on the forearm.
b. Press lightly on the fingertips.
c. Grasp a fold of skin on the sternal area.
d. Grasp a fold of skin on the back of the hand.
ANS: C
To assess skin turgor, grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release. Since the skin on the back of the hand is normally loose and thin, turgor is not reliably assessed at that site. Pressing lightly on the forearm can be used to assess for pitting edema or pain or sense of touch. Pressing lightly on the fingertips and observing nail color is assessing capillary refill.
You might also like to view...
The client who reports having difficulty sleeping at night asks the nurse for suggestions to enhance getting a good night's sleep. Which recommendations may be beneficial to this client?
Select all that apply. 1. Performing 30 minutes of exercise prior to going bedtime. 2. Setting a regular bedtime. 3. Establishing a relaxation routine at bedtime. 4. Avoiding alcohol. 5. Watching television to assist in falling asleep.
The nurse supervisor would like to delegate accreditation preparation activities to the nurse manager. The manager is unsure of what is expected and has no experience with accreditation
How should the manager respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. "I'll be glad to work on this task." 2. "I will need some education on the accreditation process before I can accept this task." 3. "I don't have time to add that to my work." 4. "Please tell me more about what this assignment entails." 5. "I'm not interested in working on this project."
A science teacher is talking to a group of fifth graders about the role of "spit." During the course of the discussion, the teacher asks the students which of the following are functions of saliva?
A) Good protection device if someone is being attacked B) Will have more saliva production when anxious, such as right before a test C) Has antibacterial action to help keep the mouth clean D) Secretes acid to chemically break down fatty foods like French fries E) Secretes the enzyme pepsin
Which conditions are examples of an inflammatory response to injury, but without infection? (Select all that apply.)
a. Appendicitis b. Bacterial pneumonia c. Dermatitis d. Myocardial infarction e. Otitis media f. Osteoarthritis g. Sprained ankle h. Tonsillitis