Author Question: During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle ... (Read 29 times)

HCHenry · **on:** Jun 25, 2018

During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle or on the forearm to test the:

a. Mobility and turgor.
b. Patient's response to pain.
c. Percentage of the patient's fat-to-muscle ratio.
d. Presence of edema.

Question 2

The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate:

a. Epigastric hernia.
b. Pyloric obstruction.
c. Hypoactive bowel sounds.
d. Hyperactive bowel sounds.

shailee · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
Pinching a fold of skin under the clavicle or on the forearm is done by the nurse to determine mobility and turgor.

Answer to Question 2

ANS: D
A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as observed with pyloric obstruction or large hiatus hernia