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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When a primigravida client confides in the practical nurse (PN) about being in an abusive relationship, the primary concern is the safety and well-being of the client and her unborn child. Providing contact information for a women's shelter is the most appropriate response in this situation. Women's shelters provide a safe haven for individuals experiencing domestic violence and can offer immediate assistance, including shelter, counseling, legal support, and other resources.
Let's evaluate why the other options are incorrect:
B. Safety plan to keep in a purse at all times:
While a safety plan is essential for individuals experiencing domestic violence, providing a safety plan alone may not address the immediate danger the client is facing. It is crucial to prioritize the client's safety by connecting her with a women's shelter where she can receive comprehensive support.
C. Visit summary documenting the report of abuse:
While it is important to document any reports of abuse, providing a visit summary alone does not address the urgent need for the client's safety. Documentation can be helpful for future reference, but immediate action should be taken to ensure the client's well-being.
D. Paperwork needed to file a restraining order:
Filing a restraining order is a legal step that may be necessary in cases of domestic violence, but it should be pursued after ensuring the client's immediate safety. Providing paperwork alone does not address the client's immediate need for a safe environment. Connecting the client with a women's shelter is a more appropriate course of action to ensure her safety and well-being.
Correct Answer is B
Explanation
A. Explaining the examination and asking the client to sign the consent form is not within the PN's scope of practice. It is the responsibility of the healthcare provider performing the procedure to explain the risks, benefits, and alternatives of the exam and to obtain informed consent from the client.
B. Checking the medical record for the correct signed consent form prior to the examination is an essential role for the practical nurse. It ensures that informed consent has been obtained and documented before proceeding with any invasive procedure, aligning with the PN's responsibility to verify necessary documentation.
C. Explaining to a family member and obtaining their signature on the consent form may be appropriate only if the client is unable to provide consent and has a legal representative. However, obtaining consent and explaining the procedure is still the responsibility of the healthcare provider, not the PN.
D. Asking if the client understands the exam and why the consent form must be signed is part of the PN's role in ensuring that the client is informed, but the PN cannot assume responsibility for explaining the procedure in detail. This should be done by the healthcare provider who will perform the exam.
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