The nurse is caring for an older patient with thin subcutaneous ...

[silviawilliams41]

The nurse is caring for an older patient with thin subcutaneous tissue. What actions should the nurse take to ensure the patient's comfort and safety?
 
  Select all that apply.
 
  1. Apply warm blankets
  2. Keep the room cool
  3. Use a lift sheet to reposition in bed
  4. Assess skin for areas of breakdown
  5. Encourage frequent position changes

Question 2

The nurse is planning to assess an African American patient's integumentary status. Which finding indicates the presence of cyanosis in this patient?
 
  1. yellow hue in the eyes
  2. bluish-tinged nail beds
  3. cherry-red lips
  4. orange-green cast to the skin

[morganmarie791]

Answer to Question 1

Correct Answer: 1, 3, 4, 5
The older patient with thin subcutaneous tissue is at risk for hypothermia. Applying warm blankets will reduce this risk. The room should be warm, not cool. This patient is also at risk for pressure ulcer formation. Assessing the skin for areas of breakdown and frequent position changes will reduce this risk. Using a lift sheet to reposition in bed will reduce the risk of skin tears because of the flattened dermalepidermal junction.

Answer to Question 2

Correct Answer: 2
Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae. A yellowish hue indicates the presence of jaundice. Cherry-red lips are associated with carbon monoxide poisoning. An orange-green cast to the skin is not associated with any specific disorder.

[silviawilliams41]

Gracias!

[recede]

Excellent