The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Check skin for unusual bruising.

Palpate mucus membranes for cracks.

Monitor color of nailbeds.

Assess skin folds of perineal area.

Observe skin under the breasts.

Answer and Explanation

Correct Answer : D,E

A. Check skin for unusual bruising is not directly related to the client's diaphoretic condition. While bruising may be relevant in some cases, it is not the priority in this scenario, where the focus is on managing moisture and skin integrity.

B. Palpate mucus membranes for cracks is not as relevant in this situation. Cracks in the mucus membranes could indicate dehydration or other issues, but the primary concern for a diaphoretic client is skin breakdown due to moisture.

C. Monitor color of nailbeds is important in general assessment, but it is not directly related to the client's diaphoretic condition. Nailbed color may indicate circulation issues, but it is not a primary concern for this scenario.

D. Assess skin folds of perineal area is important because moisture from perspiration can accumulate in skin folds, increasing the risk for skin breakdown or infection, especially in overweight clients.

E. Observe skin under the breasts is also critical. The skin under the breasts is prone to moisture buildup, which can lead to irritation, fungal infections, or skin breakdown in overweight clients. Regular assessment of this area is necessary to prevent complications.

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Correct Answer is A

Explanation

A. Reduce the stimuli in the area before continuing the teaching is the best action. Sensory overload can interfere with a client's ability to learn effectively. By reducing distractions and environmental stimuli, the nurse can create a more conducive learning environment.

B. Reassure the client that the skill is not difficult to learn may be helpful, but it does not address the immediate issue of sensory overload. The client needs to be in an environment where they can focus and process information before reassurance is effective.

C. Provide the client with step-by-step written instructions may be helpful later, but in the context of sensory overload, the priority is to first reduce the stimuli. Written instructions can be given once the client is in a calmer state.

D. Demonstrate the skill, speaking slowly and using simple terms is a helpful teaching strategy, but if the client is experiencing sensory overload, the first step should be to reduce the environmental stimuli. Once the environment is conducive to learning, the nurse can proceed with demonstrating the skill.

A. Turgor. B. Blood pressure. C. Weight. D. Lung sounds.

Correct Answer is C

Explanation

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

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The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Correct Answer is A

Explanation

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

Correct Answer is C

Explanation

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