A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

Sclera

Dorsal surface of the foot

Pinnae of the ears

Palmar surface of the hand

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Sclera is correct. The sclera, or the white part of the eye, is a reliable site to assess for jaundice, especially in dark-skinned individuals. Jaundice causes a yellowish discoloration of the sclera due to the accumulation of bilirubin in the blood. This yellowing is often more noticeable in the sclera than in other parts of the body.

Choice B Reason:

Dorsal surface of the foot is incorrect. The dorsal surface of the foot is not a reliable site for assessing jaundice, particularly in dark-skinned individuals. The skin on the feet may not show the yellow discoloration as clearly as the sclera.

Choice C Reason:

Pinnae of the ears is incorrect. The pinnae, or outer parts of the ears, are not typically used to assess for jaundice. The skin in this area may not show the yellow discoloration as effectively as the sclera.

Choice D Reason:

Palmar surface of the hand is incorrect. While the palms can sometimes show signs of jaundice, they are not as reliable as the sclera. The yellow discoloration may be less noticeable on the palms, especially in dark-skinned individuals.

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Correct Answer is C

Explanation

Choice A reason: Cover

Covering a wound with slough is not an appropriate intervention. Slough is a type of necrotic tissue that can impede the healing process by providing a medium for bacterial growth and preventing the formation of healthy granulation tissue. Simply covering the wound without addressing the slough can lead to infection and delayed healing.

Choice B reason: Clean

Cleaning the wound is a necessary step in wound care, but it is not sufficient on its own to address the presence of slough. While cleaning can help reduce the bacterial load and remove some debris, it does not effectively remove the slough itself. Slough often requires more targeted interventions such as debridement to be effectively managed.

Choice C reason: Debride

Debridement is the most appropriate intervention for a wound with slough. Debridement involves the removal of necrotic tissue, including slough, to promote a clean wound bed and facilitate the healing process. There are several methods of debridement, including autolytic, enzymatic, mechanical, and surgical, each with its own indications and benefits. Removing the slough allows for better assessment of the wound and promotes the formation of healthy granulation tissue.

Choice D reason: Leave Alone

Leaving a wound with slough alone is not advisable. Slough can harbor bacteria and impede the healing process, leading to chronic wounds and potential infection. Without intervention, the wound is unlikely to progress through the normal stages of healing.

A. Defamation of character B. Invasion of privacy C. Slander D. False imprisonment

Correct Answer is D

Explanation

Choice A Reason:

Defamation of character is incorrect. Defamation of character involves making false statements about someone that damage their reputation. This can be in the form of slander (spoken) or libel (written). Applying restraints without proper justification does not fall under defamation of character.

Choice B Reason:

Invasion of privacy is incorrect. Invasion of privacy involves intruding into someone’s personal life without consent. This can include unauthorized access to personal information or spaces. Applying restraints without proper justification is not an invasion of privacy.

Choice C Reason:

Slander is incorrect. Slander is a form of defamation that involves making false spoken statements that damage someone’s reputation. Applying restraints without proper justification does not involve making false statements.

Choice D Reason:

False imprisonment is correct. False imprisonment involves restraining a person without legal justification or their consent. In a healthcare setting, applying restraints without proper justification or following legal and ethical guidelines constitutes false imprisonment and violates the client’s rights.

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A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client’s wound and notes there is slough present. What would be an appropriate intervention for this wound?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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