The nurse is preparing to assess an older patient for fluid balance. Which areas of the body should the nurse use to assess for skin turgor? (Select all that apply.)
a. Hand
b. Sternum
c. Forearm
d. Forehead
e. Upper thigh
ANS: B, D
B. D. When assessing an older patient for skin turgor, skin over the forehead or sternum should be used. The skin over these areas usually retains elasticity and is therefore a more reliable indicator of skin turgor. A. C. E. The hand, forearm, or upper thigh are not reliable areas to assess for skin turgor.
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The nurse is preparing to conduct an abdominal assessment for a client who is denying abdominal pain. Which assessment will the nurse perform first?
1. Auscultate the abdomen for bowel sounds. 2. Palpate the abdomen for masses or tenderness. 3. Palpate for hernias. 4. Percuss the abdomen in all quadrants.
The nurse encourages a patient who has been vomiting to drink fluids because the body fluid lost daily must match the amount of fluid taken in to maintain homeostasis. The recommended daily amount of water for an adult is about:
a. 1000 mL. b. 1500 mL. c. 2050 mL. d. 2500 mL.
The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. Which of the following would the nurse use when documenting these observations?
A) Spastic B) Athetoid C) Ataxic D) Mixed
Mr. Williams, a 62-year-old patient, presents for a physical examination. You suspect a vitamin D deficiency. Which of the following assessment findings might lead the examiner to suspect vitamin D deficiency?
a. Spinal curvature and bowed legs b. Night blindness and dry eyes c. Neuropathy and seizures d. Nausea and insomnia