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
Choice A rationale:
Asking the client to describe the intensity of the eye pain using the numerical pain scale is not the most relevant action in this situation. The client's statement indicates a misconception about the purpose of pilocarpine eye drops, so addressing this misunderstanding should be the focus.
Choice B rationale:
Reminding the client that the action of the eye drops is to decrease internal eye pressure is the appropriate action. Pilocarpine eye drops are used to treat glaucoma by reducing intraocular pressure, not to anesthetize the eye.
Choice C rationale:
Documenting in the chart that the client understands the action and use of the eye drops might be necessary but should not be the first action taken. The priority is to correct the client's misunderstanding about the eye drops.
Choice D rationale:
Clarifying with the client that eye pain in glaucoma is uncommon, so drops are rarely needed, is not accurate. While eye pain might not be a common symptom of glaucoma, pilocarpine eye drops are specifically used to manage intraocular pressure and are not intended to address eye pain.
Correct Answer is A
Explanation
"I will be back in 30 minutes to help you get out of bed and walk around the room today.”.
Choice B rationale:
Telling the client that she must ambulate to avoid complications (Choice B) may be true, but it comes across as authoritarian and may further upset the client. It is essential to address the client's feelings of anger and approach the situation with empathy and understanding.
Choice C rationale:
Acknowledging the client's anger about the pain of ambulation (Choice C) is a good start, but it is not enough. The nurse should follow up with a plan to assist and encourage the client to walk later, promoting collaboration in the healing process.
Choice D rationale:
Informing the client about specific instructions to ambulate (Choice D) is important, but the response lacks empathy and fails to address the client's feelings. The nurse needs to consider the client's mental disability and approach the situation with sensitivity.
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