When assessing the sensory skin perception of an elderly client, ...

[Mimi]

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

Question 2

For which of the following clients would a cleansing enema most likely be indicated?
 
  A) A client who has developed gastrointestinal bleeding from overuse of NSAIDs.
  B) A client who has recently been diagnosed with Crohn disease.
  C) A client who has severe nausea and who has been vomiting frequently for the past 48 hours.
  D) A client who is scheduled to be screened for colorectal cancer the following morning.

[frankwu0507]

Answer to Question 1

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.

Answer to Question 2

D
Feedback:
Cleansing enemas are often used to remove stool from the bowel in preparation for diagnostic imaging procedures. GI bleeding and Crohn disease are usually contraindications for the use of enemas. It is unnecessary to administer enema in cases of severe nausea and vomiting.