The nurse notes that a client's skin turgor is nonelastic and the skin folds remain elevated. What should the nurse suspect is occurring with this client?

1. Dehydration
2. Lesions
3. Edema
4. Hypothermia


Answer: 1

1. A lack of water, as seen with dehydration, decreases the fullness and elasticity of the skin.
2. Lesions usually do not affect skin turgor.
3. Excess fluid would cause edema.
4. Body temperature usually does not affect skin turgor.

Nursing

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The ability to engage in productive activities and fulfilling relationships with other people, to adapt to change, and to cope with adversity is the definition of:

1. Mental illness 2. Mental disorders 3. Mental health 4. Mood disorders

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A patient taking an MAOI is seen in the clinic with a blood pressure of 170/96 mm Hg. What will the nurse ask this patient?

a. Whether any antihypertensive medications are used b. Whether the patient drinks grapefruit juice c. To list all foods eaten that day d. Whether SSRIs are taken in addition to the MAOI

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A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?

A. "The care map is developed by a nurse and identifies nursing diagnoses." B. "The care map is a plan that is used only by the nurse to provide client care." C. "The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge." D. "The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis."

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