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?
Face
Shoulders
Palm of the hands
Sclera
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A is correct because facilitating an interdisciplinary conference at the new facility for the family can help address their concerns, provide information about the client's plan of care, and promote continuity of care.
B is incorrect because referring the client and family to a social worker for assistance and a follow-up meeting is not enough to address their immediate concerns and does not involve other members of the health care team.
C is incorrect because reassuring the client's family that the same provider will provide care at the new facility may not be true and does not address their specific concerns about the level of care.
D is incorrect because telling the family that the rehabilitation facility has an excellent client care record is not enough to address their specific concerns and may sound dismissive.
Correct Answer is D
Explanation
A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.
B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.
C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.
D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate life-saving interventions.
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