The nurse presses a finger into swollen skin tissue on a? client's feet and ankles and notes that it creates an indentation. The nurse should correctly document a finding of which alteration in skin? integrity?
A) Poor turgor
B) Ascites
C) Peripheral edema
D) Hypothermia
Ans: C) Peripheral edema
Rationale: Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Skin turgor is the skin's elasticity and is assessed by gently pinching the skin over the sternum or collarbone. Skin temperature is assessed through palpation.
You might also like to view...
A client who has recently experienced a fracture is concerned about maintaining muscle strength during recuperation. Which type of exercise will the nurse recommend for this client?
1. Isometric exercise. 2. Isotonic exercise. 3. Resistive exercise. 4. Anaerobic exercise.
The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?
A) Sputum production B) Shortness of breath C) Throat discomfort D) Epistaxis
The federal agency responsible for oversight of many of the regulations for protecting the environment and minimizing environmental risks to health is the
1. Department of Health and Human Services. 2. Environmental Protection Agency. 3. Greenpeace Society. 4. Nuclear Regulation Commission. 5. Occupational Safety and Health Administration.
When assessing an elderly client's hip joint, which of the following would lead the nurse to suspect that the client has a hip fracture?
A) Internal rotation of the affected leg B) Abduction of the affected leg C) Partial weight bearing D) Thigh pain