The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that the skin remains suspended for a longer than normal period. What could this indicate?
a. Stage I pressure ulcer
b. Increased blood flow to the area
c. Localized vasodilation
d. Dehydration
D
With reduced turgor, the skin remains suspended or "tented" for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. A stage I pressure ulcer may cause warmth and erythema (redness) of an area. Skin temperature reflects an increase or decrease in blood flow. Normal reactive hyperemia (redness) is a visible effect of localized vasodilation, the body's normal response to lack of blood flow to underlying tissue.
You might also like to view...
A patient who has undergone liver transplantation is ready to be discharged home. The nurse is providing discharge teaching. Which topic will the nurse emphasize the most related to discharge teaching?
A) The patient will obtain measurement of drainage from the T-tube. B) The patient will exercise three times a week. C) The patient will take immunosuppressive agents as required. D) The patient will monitor for signs of liver dysfunction.
Dennis is a 15-year-old who wants a tongue piercing and a huge tattoo across his back. He tells his mom, "Everyone has them." Discuss tattooing and body piercings
a. Include in the discussion the social and personal implications. b. What important things need to be known about tattooing and body piercings? c. What type of care and risks are associated with piercings and tattooing?
A client has suffered a snakebite (North American pit viper) to a lower extremity. What would be the most appropriate nursing intervention?
A. Apply ice to the bite site immediately. B. Attempt to capture the snake for later identification. C. Immobilize the extremity in a position of function. D. Incise the bite and suck out the venom.
A nurse counsels a patient using two different types of asthma inhalers: a short-acting beta2 agonist and a corticosteroid. When the patient questions the purpose of the steroid inhaler, the nurse's best response would be that glucocorticoids
a. work rapidly in acute attacks. b. are used as prophylaxis for chronic asthma. c. help prevent respiratory infections. d. are used only when exposed to environmental allergens.