The nurse is assessing a client with liver disease and notes that ...

[neverstopbelieb]

The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. Which term is most appropriate for the nurse to use to describe this condition when documenting in the medical record?
 
  1. Uremia.
  2. Cyanosis.
  3. Jaundice.
  4. Carotenemia.

Question 2

The nurse is preparing to assess the client's skin, hair, and nails. Which technique will the nurse use initially during this assessment?
 
  1. Percussion.
  2. Palpation.
  3. Auscultation.
  4. Inspection.

[jonathanballen97]

Answer to Question 1

Correct Answer: 3

The nurse's findings indicate jaundice, which is due to increased levels of bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands, and soles of the feet. Uremic skin is pale and yellow, but is associated with renal, and not liver, disease. The yellow tinge seen in the patient with uremic skin is very pale and does not affect conjunctivae or mucous membranes. Cyanotic skin is bluish in color. Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with carotenemia is most visible in palms of the hands and soles of the feet. This client would not exhibit yellowing of sclerae or mucous membranes.

Answer to Question 2

Correct Answer: 4
Physical assessment of the skin, hair, and nails is conducted by inspection and then with palpation. There is no need to use percussion or auscultation to assess the client's skin, hair, and nails.