A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?

Conjunctiva

Sclera of the eye

Back of the neck

Palms of the hands

Answer and Explanation

The Correct Answer is B

Choice A Reason:
The conjunctiva can sometimes appear yellow in individuals with jaundice; however, it is not the most reliable area to inspect for jaundice. The conjunctiva may be affected by other factors such as environmental irritants or infections, which can alter its appearance.

Choice B Reason:
The sclera of the eye is the most reliable area to inspect for jaundice. The yellowing of the sclera, also known as scleral icterus, is a key indicator of jaundice. The sclera's white background provides a clear contrast, making any yellow discoloration more noticeable. This is particularly true in darker-skinned individuals, where skin changes may be less apparent.

Choice C Reason:
The back of the neck is not a reliable area to inspect for jaundice. Skin pigmentation and lighting can affect the visibility of yellowing, making it an unreliable indicator. Additionally, the back of the neck may have other skin changes unrelated to jaundice that could confuse the assessment.

Choice D Reason:
The palms of the hands are not the most reliable area to inspect for jaundice. While the palms may show yellowing, they are subject to various external factors such as manual labor or exposure to substances that can affect their color. Moreover, the palms' skin may be thicker and less transparent, making subtle changes in color more difficult to detect.

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Correct Answer is B

Explanation

Choice A reason:

Reddened intact skin is typically associated with a stage 1 pressure ulcer, where the skin is not yet broken but shows signs of redness. This stage indicates that the skin is under pressure and may be at risk for further breakdown if the pressure is not relieved.

Choice B reason:

A stage 3 pressure ulcer involves full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer presents as a deep crater, and there may be slough or eschar present. It is important to manage these ulcers carefully to prevent further deterioration and complications such as infection.

Choice C reason:

Skin loss involving up to the dermis layer is characteristic of a stage 2 pressure ulcer. In this stage, the epidermis and part of the dermis are lost, creating a shallow open wound or blister. This stage is less severe than stage 3 and requires different management strategies to promote healing and prevent progression.

Choice D reason:

Exposed bone is indicative of a stage 4 pressure ulcer, which is the most severe stage. It involves full-thickness skin loss with extensive destruction, possibly including muscle, tendon, or bone exposure. These ulcers are at high risk for serious infections, including osteomyelitis, and require aggressive medical and surgical intervention to heal.

A. Wear nonslip shoes in the house. B. Use of guns should be supervised by an adult. C. Always use seat belts. D. Avoid risky activities such as snowboarding.

Correct Answer is ["A","B","C","D"]

Explanation

Choice a reason:
Wearing nonslip shoes in the house is a preventive measure against falls, which are a leading cause of traumatic brain injuries (TBIs) in adolescents. Nonslip shoes provide better grip and stability, especially on potentially slippery surfaces like tiles or polished wood, reducing the risk of slips and falls that can lead to head injuries.

Choice b reason:
The supervised use of guns by an adult is critical in preventing accidental shootings, which can result in TBIs. Adolescents may lack the maturity and experience to handle firearms safely, and adult supervision ensures that proper safety protocols are followed, reducing the risk of accidental discharge and potential injury.

Choice c reason:
The use of seat belts is one of the most effective ways to prevent TBIs in the event of a vehicle accident. Seat belts restrain the body and prevent individuals from being thrown around inside or ejected from the vehicle, significantly reducing the likelihood of head trauma.
Choice d reason:
Avoiding risky activities such as snowboarding without proper safety equipment is essential in preventing sports-related TBIs. Snowboarding, like other high-speed sports, carries a risk of falls and collisions, which can cause head injuries. Wearing helmets and other protective gear, and engaging in these activities with caution, can mitigate this risk.

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A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?

Nursing Test Bank

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Correct Answer is B

Explanation

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