When assessing the pallor of a client with dark skin, the nurse ...

[Bernana]

When assessing the pallor of a client with dark skin, the nurse will specifically look at the:
 
  1. Buccal mucosa of the mouth
  2. Dorsal surface of the hands
  3. Ear lobe
  4. Sclera

Question 2

A female client is seen in the outpatient clinic for numerous cuts, bruises, and apparent burns. In a discussion with the client, the nurse finds that the injuries are inconsistent with the stated cause.
 
  The client also states that she is having trouble sleeping, and she appears anxious. Based on these findings, the nurse suspects that the client may be experiencing:
  1. Substance abuse
  2. Domestic violence
  3. Vascular disease
  4. Mental illness

[anoriega3]

Answer to Question 1

ANS: 1
Pallor is more easily seen in the face, buccal mucosa of the mouth, conjunctiva, and nail beds. The palmar surface of the hands may be used to detect color hues in dark-skinned clients. The ear lobe is not a good site to assess for color changes, such as pallor, in a dark-skinned client. The best site to inspect for jaundice, not pallor, is the sclera.

Answer to Question 2

ANS: 2
Injuries and trauma that are inconsistent with the reported cause; multiple injuries including bruises, cuts, and burns; and behavioral findings of difficulty sleeping and appearing anxious are all indicators of possible domestic violence. The findings are not consistent with substance abuse. Indicators of substance abuse may include frequent missed appointments or emergency depart-ment visits, having a history of changing doctors, history of activities that place the client at risk for HIV infections, complaints of insomnia or chest pain, and a family history of addiction. Peo-ple who abuse substances may have cuts, burns (especially of the fingers), needle marks, home-made tattoos, or increased vascularity of the face. These findings are not indicative of vascular disease. Symptoms of vascular disease may include edema, color changes of the lower extremi-ties, and weakened pedal pulses. These findings are not indicative of mental illness. The client is coherent.

[Bernana]

Excellent

[smrtceo]

Gracias!