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A nurse is performing a skin assessment on a client who has a dark skin. Which one of the following locations on the client’s body should the nurse observe to access for jaundice?

A.

Face

B.

Shoulders

C.

Palm of the hands

D.

Sclera

Answer and Explanation

The Correct Answer is D

Choice A reason:

Face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.

Choice B reason

Shoulders is incorrect: The shoulders are not typically indicative of jaundice.

Choice C reason:

Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.

Choice D reason:

Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.


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Related Questions

Correct Answer is C

Explanation

A. Oliguria. This is incorrect because oliguria, or decreased urine output, is a sign of fluid volume deficit, not fluid volume overload.

B. Bradycardia. This is incorrect because bradycardia, or slow heart rate, is not a typical sign of fluid volume overload, unless the client has a cardiac condition that affects the heart's response to fluid overload.

C. Dyspnea. This is correct because dyspnea, or difficulty breathing, is a common sign of fluid volume overload, as excess fluid accumulates in the lungs and impairs gas exchange.

D. Poor skin turgor. This is incorrect because poor skin turgor, or decreased elasticity of the skin, is a sign of dehydration, not fluid volume overload.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Completed Sentence: The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia. Rationale: Hemorrhagic Stroke: This is a serious condition that can occur as a complication of a high spinal cord injury. Due to the injury at T4, the client may be at risk for blood pressure dysregulation, which can lead to a hemorrhagic stroke. Autonomic Dysreflexia: This condition is characterized by a sudden increase in blood pressure, often triggered by stimuli such as a full bladder, bowel distention, or pain. In this client, the headache rated 9/10, diaphoresis, flushed skin, agitation, labored breathing, and elevated blood pressure (185/105 mm Hg) are indicative of autonomic dysreflexia.

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