When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?
Redo the initial assessment and document current findings
Perform and document a focused assessment of skin integrity
Correct the initial assessment form
Conduct and document an emergency assessment
The Correct Answer is B
A. Redo the initial assessment and document current findings:
This option suggests repeating the entire initial assessment. While reassessment is important, redoing the entire initial assessment may not be necessary. Instead, a focused assessment on the specific area of concern (skin integrity) is more appropriate.
B. Perform and document a focused assessment of skin integrity:
This is the recommended choice. If unexpected findings are observed during care, such as reddened areas over bony prominences, it is important to conduct a focused assessment on the skin to identify any issues and document the findings accurately.
C. Correct the initial assessment form:
Simply correcting the initial assessment form may not address the immediate need for assessing and addressing the reddened areas. It is more crucial to perform a focused assessment on the skin.
D. Conduct and document an emergency assessment:
Reddened areas over bony prominences may not necessarily indicate an emergency. However, addressing the issue promptly is important. A focused assessment would be more appropriate than conducting a full emergency assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dorsal surface of the foot:
The skin on the dorsal surface of the foot may have more pigmentation, making it potentially more challenging to detect cyanosis in individuals with dark skin.
B. Pinnae of the ears:
The ears may have variable pigmentation, and the presence of hair can affect the visibility of cyanosis. The skin on the pinnae may not be as thin as the skin on the dorsal surface of the hand.
C. Dorsal surface of the hand
When assessing for cyanosis in a client with dark skin, the nurse should examine areas with less pigmentation or areas where the skin is thin. The dorsal surface of the hand is often a suitable site, as it is less pigmented and can show bluish discoloration if cyanosis is present.
D. Conjunctivae:
The conjunctivae (the mucous membranes lining the inner surface of the eyelids and covering the white part of the eyes) are not a reliable site for assessing cyanosis in individuals with dark skin. Mucous membranes may not show cyanosis as prominently as the skin.
Correct Answer is A
Explanation
A. “I will begin upon the client’s admission to the facility.”
Effective discharge planning should start upon the client's admission to the facility. It is an ongoing process that involves assessing the patient's needs, planning for post-discharge care, and ensuring a smooth transition from the hospital to the next level of care. Early initiation of discharge planning allows the healthcare team to address any potential barriers, educate the patient and their family, and coordinate necessary resources for a successful transition.
B. “I will begin once the client’s insurance company approves discharge coverage.”
Waiting for insurance approval may delay the discharge planning process and hinder the timely coordination of resources needed for post-discharge care.
C. “I will begin 48 hr before the client’s discharge.”
Waiting until 48 hours before discharge may not allow sufficient time to address all aspects of the discharge plan, potentially leading to rushed or incomplete preparations.
D. “I will begin once the client’s discharge order is written.”
Waiting for the discharge order may delay the start of the planning process, and effective discharge planning should be initiated earlier to ensure comprehensive and patient-centered care.
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