Chapter 13: Assessment and Care of Patients with Fluid and Electrolyte Imbalances Graded A+

1. The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? a. Notify the physician. b. Examine dependent body areas. c. Assess turgor on the client's forehead. d. Document the finding and continue to monitor. ANSWER: C Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment)