Nokea
The nurse is assessing a client who is hospitalized for dehydration from persistent vomiting. How would the nurse assess that the client's skin turgor is related to the state of dehydration?
- A. When the nurse pinches up skin of the hand, there is rapid recoil.
- B. The client has wrinkles of the chest.
- C. The nurse grasps the skin over the sternum between the thumb and forefinger with slow recoil observed.
- D. The nurse grasps the skin over the sternum between the thumb and forefinger with rapid recoil observed.
Correct Answer: C
Rationale: Poor skin turgor, indicated by slow recoil when the skin over the sternum is pinched, suggests dehydration. Rapid recoil indicates normal hydration. Wrinkles on the chest are not a specific indicator of dehydration.
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An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned about the possibility of having melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of?
- A. Senile keratoses
- B. Senile lentigines
- C. Melanoma
- D. Freckles
Correct Answer: B
Rationale: Small, brown, pigmented, benign lesions, known as liver spots or senile lentigines, form on the hands and forearms of older people. Small, yellow or brown, raised lesions called senile keratoses may appear on the face and trunk and are precancerous and require close observation. Melanoma is diagnosed by biopsy and generally has irregular borders and is dark in color.
During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?
- A. Sebum deficiency
- B. Fluid retention
- C. Dehydration
- D. Protein deficiency
Correct Answer: B
Rationale: Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.
A female client comes to the clinic and tells the nurse, 'I am getting all these little hairs on my chin. I never had them before I turned 50.' What does the nurse understand is the cause of the terminal hairs on the face?
- A. Overproduction of melanin
- B. Increased secretion of sebum
- C. Decline in the number of eccrine glands
- D. Decreased ratio of estrogen to androgen hormones
Correct Answer: D
Rationale: After menopause, some women develop sparse terminal hairs about their face as the ratio of estrogen to androgen hormones decreases. An overproduction of melanin would cause altered color of the skin. Increased secretion of sebum is an oily substance that may cause blackheads and pustules. A decline in the number of eccrine glands will cause a decrease in perspiration in the older adult.
A client has joined a rowing team and has been enjoying the activity for approximately 1 month. The client comes to the clinic for a routine physical examination and shows the nurse the hands, which are observed to have thickened areas in several areas. What does the nurse recognize these are in response to the repeated friction of the oars?
- A. Calluses
- B. Senile keratosis
- C. Senile lentigines
- D. Rheumatoid nodules
Correct Answer: A
Rationale: Areas of skin subjected to friction, such as where a pencil is held repeatedly, have accelerated rates of epidermal cell production. A callus, which is a thick layer of epidermal cells, forms in response to recurring friction on an area of skin. Senile keratosis is small, yellow or brown raised lesions that appear on the face and trunk in an older adult client. Senile lentigines are also known as liver spots and are found on the hands and forearms of older people. Rheumatoid nodules affect those clients with rheumatoid arthritis.
The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?
- A. Radiation
- B. Evaporation
- C. Conduction
- D. Convection
Correct Answer: C
Rationale: Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water. Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body.