The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client?
1. Poor skin turgor.
2. Elevated body temperature.
3. Diminished pain sensation.
4. Thin epidermis.
5. Dry skin.
Correct Answer: 1,3,4,5
Rationale 1: The older person is more prone to impaired skin integrity because of decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis.
Rationale 2: Elevated body temperature does impact a person's skin integrity, but this could occur at any age, and not just in an older client.
Rationale 3: The older person is more prone to impaired skin integrity because of diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch.
Rationale 4: The older person is more prone to impaired skin integrity because of generalized thinning of the epidermis.
Rationale 5: The older person is more prone to impaired skin integrity because of increased dryness due to a decrease in the amount of oil produced by sebaceous glands.
You might also like to view...
Your clients lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?
A) Metabolic acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Respiratory acidosis
Which component of budgeting might normally be addressed in the annual performance evaluation for a nurse manager?
a. Including in the labor budget costs for overtime and benefits b. Managing variances in nursing overtime costs and supply usage c. Accurately predicting revenues on the basis of unit of service d. Providing qualitative analysis for variances in the capital budget
A clinic patient complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?
A) Ask the doctor for an order for an MRI B) Perform a focused assessment C) Prepare the patient for a spinal tap D) Perform a generalized assessment
A nurse suspects that an adolescent may have community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA). What would the nurse expect to assess? Select all that apply
A) Participation in contact sport B) Recent cut on the lower leg C) History of a recent sore throat D) Raised fluctuant lesions E) Erythematous rash over the trunk and face