When assessing a patient's skin, the nurse needs to know that ...

[Tazate]

When assessing a patient's skin, the nurse needs to know that
 
  a. Restricted movement can increase blood circulation.
  b. Paralyzed patients have normal sensory function.
  c. Loss of subcutaneous tissue may increase the rate of wound healing.
  d. Moisture on the skin can lead to skin maceration.

Question 2

The nurse is caring for a patient of Asian descent who speaks very little English. The nurse is especially concerned and attempts to develop a trusting relationship with the patient. She does this knowing that
 
  a. Cultural assessment needs to be done quickly to provide the best care early.
  b. Miscommunication cannot be tolerated in cultural assessment.
  c. The goal is to get the patient to conform to American health care norms.
  d. Cultural assessment is intrusive in contrast to other types of interviews.

[bblaney]

Answer to Question 1

D
Moisture on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require help to turn and change positions. Patients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue, which results in impaired or delayed wound healing.

Answer to Question 2

D
In contrast to other types of interviews, cultural assessment is intrusive and time-consuming and requires a trusting relationship between participants. Miscommunication commonly occurs in intercultural interactions as the result of language and communication differences between and among participants, as well as differences in interpreting each other's behaviors. The goal is to generate knowledge about the patient's values, beliefs, and practices about nursing and health care.

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