The nurse is examining a client with dark skin. In assessing for ...

[burchfield96]

The nurse is examining a client with dark skin. In assessing for pallor, at which of the following will the nurse specifically look?
 
  a. Lips and tongue
  b. Skin creases and folds
  c. Hard palate
  d. Sclera

Question 2

A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery. Upon assessment, the nurse expects to find
 
  a. Blood in the sputum.
  b. Distended jugular vein.
  c. Peripheral edema.
  d. Crackles in the lungs.

[Viet Thy]

Answer to Question 1

A
Pallor is more easily seen in the palms, soles, lips, tongue, earlobes, and nail beds.
Skin creases and folds are darker than the rest of the body in the dark-skinned client.
The hard palate is not a good site to assess for colour changes such as pallor.
The best site to inspect for jaundice, not pallor, is the sclera.

Answer to Question 2

D
The left coronary artery supplies the left ventricle of the heart; damage to the muscle in the left ventricle leads to pulmonary congestion and frothy sputum, and crackles may be heard. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Blood in the sputum is indicative of an infection such as tuberculosis.

[burchfield96]

Gracias!

[cdmart10]

TYSM