The nurse is preparing a client for a detailed assessment of the ...

[Davideckstein7]

The nurse is preparing a client for a detailed assessment of the integumentary system. Which statements by the nurse are useful to prepare the client for this examination?
 
  Select all that apply.
  1. Please remove all jewelry so that I can conduct a full assessment.
  2. I will turn the temperature down in the exam room before we begin.
  3. Use this blanket to cover up until we are ready to begin.
  4. I will be touching your skin as part of the process.
  5. I will need you to take off your head dress for the entire examination.

Question 2

While performing a skin assessment for a client, the nurse notes that the client becomes pales and diaphoretic.
 
  The client's vital signs have remained stable since the beginning of the examination: blood pressure 138/76 mmHg, heart rate is 88 beats per minute, and respiratory rate is 18 breaths per minute. Which is the priority response by the nurse?
  1. The nurse immediately raises the client's head of bed.
  2. The nurse asks the client, Are you feeling anxious during this assessment?
  3. The nurse immediately notifies the client's healthcare provider.
  4. The nurse provides the client with  cup of orange juice.

[ricroger]

Answer to Question 1

Correct Answer: 1, 3, 4
Jewelry can often hinder the nurse's ability to conduct a complete skin assessment. This statement is appropriate to prepare the client for the exam. It is often necessary to expose certain areas of the skin during the assessment process. A drape should be provided to the client to cover all areas that are not being assessed. This action is appropriate prior to beginning the exam. Palpating the skin is part of an integumentary assessment. It is important to state this to the client before the examination. The temperature of the room should be warm, yet comfortable. Turning down the temperature without first asking the client's input is not appropriate. While it may be necessary for the client's head dress to be removed during certain portions of the exam, it is not necessary for the entire examination process. This statement does not take the client's cultural background into consideration and is not appropriate.

Answer to Question 2

Correct Answer: 2

Anxiety is commonly associated with the development of pallor and diaphoretic skin. This can often be resolved by determining the client's level of anxiety and acknowledging the client's anxiety. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client's vital signs have remained stable. The nurse does not need to alter the position of the client's head of bed. The nurse does not need to notify the client's healthcare provider. Prior to providing the client with orange juice, the nurse would want to determine if the client was feeling anxious. The client's serum glucose level should be assessed if hypoglycemia was suspected.

[Davideckstein7]

Correct answers!

[ricroger]

Great! Please up vote