Author Question: The client is visiting the healthcare provider's office for a head-to-toe assessment. During the ... (Read 93 times)

123654777 · **on:** Jun 25, 2018

The client is visiting the healthcare provider's office for a head-to-toe assessment. During the nurse's assessment of the client's skin, the nurse notes that the client is pale. Which assessment data may be related to the client's color?

Select all that apply.
1. Client's blood pressure is 96/62.
2. The client states, I just smoked a cigarette before I came in the office.
3. The client's oxygen saturation level is 86 on room air.
4. The client states, I have been diagnosed with osteoporosis.
5. The client states, It is snowing again outside with a wind chill factor of -11 degrees Fahrenheit.

Question 2

The nurse is conducting a focused interview on the client's integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders.

Which question by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview?
Select all that apply.
1. How much time do you spend outdoors?
2. How do you care for your skin?
3. Do you have any tattoos or body piercings?
4. Have you noticed any drainage from your skin?
5. Do you take any medications on a regular basis?

abro1885 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1, 2, 3, 5
Pallor may be seen in the client with hypotension. It can be produced by the sympathetic nervous stimulation that results in vasoconstriction due to smoking cigarettes. The client with a decreased oxygen saturation level may exhibit pallor. A cold environment can produce vasoconstriction and pallor. It is not normally associated with osteoporosis.

Answer to Question 2

Correct Answer: 1, 2, 3, 5

The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma. The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder. Tattoos and body piercings can increase the client's risk for developing an integumentary disorder. Certain medications, if taken on a regular basis, can increase the client's risk for developing skin disorders. When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors.