When gathering data about a client with dark skin tones, which site should the practical nurse (PN) observe?
Hands and feet.
Forehead and face.
Finger and toe nails.
Sclera and mucous membranes.
The Correct Answer is D
This is the best site for the PN to observe because it allows for the detection of changes in color, such as pallor, cyanosis, or jaundice, that may not be visible on the skin surface. The sclera and mucous membranes are less pigmented than the skin and reflect the underlying blood flow and oxygenation.
A. Hands and feet are not the best site for the PN to observe because they may be affected by peripheral circulation, temperature, or edema, which can alter the color of the skin.
B. Forehead and face are not the best site for the PN to observe because they may have increased pigmentation or variations in tone that can mask changes in color.
C. Finger and toenails are not the best site for the PN to observe because they may be affected by nail polish, fungal infection, or trauma, which can alter the color of the nails.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The Herpes zoster (shingles) vaccination is recommended for adults aged 60 years and older, regardless of whether they have had shingles or chicken pox before. The vaccine can reduce the risk of developing shingles and its complications, such as postherpetic neuralgia.
The other options are not correct because:
A. The vaccine is useful even if the person has had a case of shingles before, as shingles can recur in some people. The vaccine can prevent or reduce the severity of future episodes.
C. The person needs to get this vaccination even if they have had chickenpox, as shingles are caused by the reactivation of the same virus that causes chickenpox (varicella-zoster virus). The vaccine can boost the immunity against the virus and prevent it from reactivating.
D. The vaccination does not minimize outbreaks of cold sores, as cold sores are caused by a different virus (herpes simplex virus). The vaccine has no effect on this virus or its symptoms.
Correct Answer is A
Explanation
The correct answer is Choice A:
"Are you planning to obey the voices?.”. Choice A rationale:
The PN should ask the client if he plans to obey the voices because it helps assess the potential risk of harm to himself or others. If the client indicates an intention to follow the voices' commands to harm someone, it indicates a serious concern for safety and may require immediate intervention to protect the client and others.
Choice B rationale:
While asking if the client believes the voices are real is important for understanding the client's perception of the situation, it may not immediately address the risk of harm that the client or others might be facing.
Choice C rationale:
Asking if the client has taken any hallucinogens is relevant to explore possible substance- induced psychosis, but this question should be asked later in the assessment process. The priority is to assess immediate safety concerns related to the client's compliance with the voices' instructions.
Choice D rationale:
Inquiring about when the voices began is important, but it is not the most urgent question in this situation. Although the onset of the symptoms is relevant, addressing the potential for harmful actions should be prioritized.
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