An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What term does the nurse document for this finding?
Blanching
Warmth
Redness
Nonblanching
The Correct Answer is A
Choice A reason: Blanching is the term that the nurse documents for this finding, because it describes the temporary whitening of the skin when pressure is applied. Blanching indicates that the blood vessels in the skin are constricted or compressed, and that the blood flow is reduced or interrupted. Blanching can be a normal response to cold, stress, or pressure, or it can be a sign of a problem, such as ischemia, infection, or inflammation.
Choice B reason: Warmth is not the term that the nurse documents for this finding, because it describes the increased temperature of the skin, not the color change. Warmth indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced. Warmth can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.
Choice C reason: Redness is not the term that the nurse documents for this finding, because it describes the original color of the skin, not the color change. Redness indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced, as explained above. Redness can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.
Choice D reason: Nonblanching is not the term that the nurse documents for this finding, because it describes the opposite of what the nurse observed. Nonblanching means that the skin does not turn white when pressure is applied, but rather remains red or purple. Nonblanching indicates that the blood vessels in the skin are damaged or ruptured, and that the blood has leaked into the surrounding tissues. Nonblanching can be a sign of a serious problem, such as bruising, bleeding, or necrosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Obtaining a PAPR mask is not a step in preparing a sterile field. A PAPR mask is a powered airpurifying respirator that protects the wearer from airborne contaminants. It is not required for setting up a sterile field, unless the client has a highly infectious disease.
Choice B reason: Do not turn away from the sterile field is a step in preparing a sterile field. Turning away from the sterile field can contaminate the field or the items on it. The nurse should always face the sterile field and keep it in view.
Choice C reason: Add items to the sterile field by dropping them gently is a step in preparing a sterile field. Dropping items gently onto the sterile field prevents splashing or touching the field or the items. The nurse should open the sterile packages away from the field and drop the items close to the edge of the field.
Choice D reason: Covering the sterile field once it is set up is not a step in preparing a sterile field. Covering the sterile field can compromise its sterility and create moisture that can harbor microorganisms. The nurse should not cover the sterile field unless it is necessary to move it or store it for later use.
Choice E reason: Preparing the client before setting up the sterile field is a step in preparing a sterile field. Preparing the client involves explaining the procedure, obtaining consent, providing privacy, and positioning the client. The nurse should prepare the client before setting up the sterile field to avoid leaving the field unattended or exposing it to the client's body fluids.
Correct Answer is C
Explanation
Choice A reason: Calling the chaplain for support is not the priority nursing intervention for a client who speaks only Spanish. The chaplain may not be able to communicate with the client or understand their needs. This choice does not address the language barrier or the client's reason for admission.
Choice B reason: Verifying the reason for admission is an important nursing intervention, but it is not the priority for a client who speaks only Spanish. The nurse cannot verify the reason for admission without communicating with the client or their family. This choice does not address the language barrier or the client's safety.
Choice C reason: Requesting a medical interpreter is the priority nursing intervention for a client who speaks only Spanish. The medical interpreter can facilitate communication between the nurse and the client, and help the nurse assess the client's condition, reason for admission, and needs. This choice addresses the language barrier and the client's safety.
Choice D reason: Giving the client a tour of the unit is not the priority nursing intervention for a client who speaks only Spanish. The client may not understand the tour or the information given by the nurse. This choice does not address the language barrier or the client's reason for admission.
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