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","B","C","D","E","F"]
Explanation
A. This is a correct action. Firmly massaging the uterine fundus can help contract the uterus and reduce bleeding by expelling clots and compressing blood vessels.
B. This is a correct action. Providing emotional support can help calm the client and reduce anxiety, which can worsen bleeding by increasing heart rate and blood pressure.
C. This is a correct action. Administering oxygen can help improve tissue perfusion and oxygenation, which can prevent hypoxia and shock due to blood loss.
D. This is a correct action. Weighing the perineal pads can help estimate the amount of blood loss and monitor the effectiveness of interventions to control bleeding.
E. This is a correct action. Inserting an indwelling urinary catheter can help empty the bladder and prevent it from displacing or compressing the uterus, which can interfere with uterine contraction and increase bleeding.
F. This is a correct action. Administering methylergonovine can help stimulate uterine contraction and reduce bleeding by constricting blood vessels in the uterus.
Correct Answer is A
Explanation
A. Autonomy is the ethical principle that respects the right of clients to make their own decisions and choices regarding their health care. Informed consent is a process that ensures that clients are fully informed of the benefits, risks, alternatives, and consequences of a proposed treatment or procedure, and that they voluntarily agree to it.
B. Nonmaleficence is the ethical principle that obliges health care providers to do no harm to clients, either intentionally or unintentionally. Informed consent does not directly promote this principle, although it may help to prevent harm by disclosing potential risks and complications.
C. Justice is the ethical principle that requires fair and equal treatment of all clients, regardless of their personal characteristics, preferences, or values. Informed consent does not directly promote this principle, although it may help to ensure that clients are not coerced or manipulated into accepting a treatment or procedure that they do not want or need.
D. Fidelity is the ethical principle that requires health care providers to be faithful and loyal to their clients, and to honor their commitments and promises. Informed consent does not directly promote this principle, although it may help to establish trust and rapport between clients and providers.
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