The nurse best displays an understanding of the role the skin plays in monitoring the body sys-tems and their ability to function properly when documenting which of the following regarding a 70-year-old client?
1. Skin appears generally jaundiced.
2. Dryness noted on heels and elbows bilaterally.
3. Skin tears present on upper left and right arms.
4. Skin on the hands and feet is slightly cool to the touch.
ANS: 1
The skin often reflects a change in physical condition by alterations in color, thickness, texture, turgor, temperature, and hydration. The observation of the skin's jaundice appearance reflects possible liver pathology. While the remaining options are appropriately related to abnormal skin, they are of less importance and/or seen in the older adult.
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