When assessing the sensory skin perception of an elderly client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment?
A) Ability to identify sharp and dull touch
B) Ability to identify fine touch
C) Ability to differentiate temperature change
D) Ability to sense vibrations
B
Feedback:
Stroking the client's skin with a cotton ball at various places on both sides of the body helps to determine the client's ability to identify fine touch. The nurse uses both the pointed and the curved ends of a safety pin to determine if the client can discriminate between sharp and dull touch. The nurse touches the client with warm and cold containers to assess the client's ability to identify differences in temperature. The client's ability to sense vibrations is determined by striking a tuning fork and placing the stem on bony areas, such as the wrist or along the shin.
You might also like to view...
An older male patient comes to the clinic with complaints of chills, malaise, myalgia, localized pain, dysuria, nocturia, and urinary retention. The nurse would most likely suspect that the pa-tient has
a. acute cystitis. b. urinary tract infection. c. pyelonephritis. d. prostatitis.
The nurse is developing a teaching plan for a child who is to have his cast removed. Which of the following would the nurse most likely include?
A) Applying petroleum jelly to the dry skin B) Rubbing the skin vigorously to remove the dead skin C) Soaking the area in warm water every day D) Washing the skin with dilute peroxide and water
Nurses are accountable for all decisions they make regarding patient care. Identify the best defense for initiating or changing any specific nursing intervention
a. Nursing administration has informed all units that they must update all current in-terventions. b. A new intervention has been identified as less costly to patient and hospital. c. The success of a new intervention is sup-ported by strong empirical evidence. d. The charge nurse has read a particularly good idea for a new intervention in a re-putable nursing journal.
A multigravida gave birth to an 18-week fetus last week. She is in the clinic for follow-up and notices that her chart states she has had one abortion
The patient is upset over the use of this word. How can the nurse best explain this terminology to the patient? 1. "Abortion is the medical term for all pregnancies that end before 28 weeks." 2. "Abortion is the word we use when someone has miscarried." 3. "Abortion is how we label pregnancies that end in the second trimester." 4. "Abortion is what we call all babies who are stillborn."