An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding?

Choice A Reason:

Get the most difficult questions over with first is not the best approach because starting with the most difficult questions may put the client on the defensive or make them feel uncomfortable, hindering open communication. It's important to build rapport and establish trust with the client before addressing sensitive topics.

Choice B Reason:

Asking questions in a vague, non-specific format is not effective because vague and non-specific questions may result in ambiguous or incomplete responses, making it difficult to gather accurate information about the client's alcohol and substance use. Clear and specific questions are necessary to obtain relevant details.

Choice C Reason:

Sharing personal values to put the client at ease is not recommended as it can compromise the nurse's professional boundaries and may influence the client's responses. The focus of the interview should be on the client, and the nurse should maintain a neutral and non-judgmental stance.

Choice D Reason:

Begin with questions that are less sensitive in nature is the best approach because it allows the nurse to establish rapport and build trust with the client before addressing more sensitive topics such as alcohol and substance use. Starting with less threatening questions helps the client feel more comfortable and willing to disclose information, facilitating open communication and rapport-building.

Choice A Reason:
Testing feet for a positive Babinski reflex is wrong. The Babinski reflex is a neurological test that assesses upper motor neuron function, particularly in the lower extremities. However, it is not relevant to assessing cold feet, and testing for the Babinski reflex would not provide useful information in this situation.
Choice B Reason:
Observing color of the feet and toes is wright. Observing the color of the feet and toes can provide important information about circulation. Pallor, cyanosis, or mottling may indicate inadequate blood flow or perfusion to the extremities, which could contribute to cold feet.
Choice C Reason:
Measuring skin elasticity around the ankles is wrong. Skin elasticity assessment is more relevant for evaluating hydration status or tissue turgor. While it may be useful in certain contexts, it is not directly related to assessing cold feet and peripheral circulation. Therefore, it is not necessary before covering the client's feet in this scenario.
Choice D Reason:
Assessing volume of the pedal pulses is wright. Assessing the volume of the pedal pulses (such as dorsalis pedis and posterior tibial pulses) provides information about peripheral vascular status. Weak or absent pulses may indicate compromised circulation, contributing to cold feet.
Choice E Reason:
Palpating dorsal surface of feet for warmth is wright. palpating the dorsal surface of the feet for warmth helps assess peripheral perfusion. Coolness to touch may indicate decreased blood flow to the extremities, while warmth suggests adequate circulation.