Nokea
A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next?
- A. Nail bed inspection
- B. Hemoglobin and hematocrit
- C. Skin turgor assessment
- D. Capillary refill time
Correct Answer: B
Rationale: Pallor conjunctivae may indicate anemia, so the nurse should assess hemoglobin and hematocrit levels next to evaluate for possible anemia.
You may also like to solve these questions
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?
- A. Are you using lotion on your skin?
- B. Do you have a family history of this?
- C. Do your arms itch?
- D. What medications are you taking?
Correct Answer: D
Rationale: Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.
A nurse teaches a client to perform total skin self-examination on a monthly basis. Which statements should the nurse include for this client's teaching? (Select all that apply.)
- A. Look for asymmetry of shape and irregular borders.
- B. Assess for color variation within each lesion.
- C. Monitor for symmetry and regular borders.
- D. Monitor for edema or swelling of tissues.
- E. Focus your assessment on skin areas that itch.
Correct Answer: A,B
Rationale: Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape and irregular borders, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.
A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.)
- A. Excessive moisture under skin folds
- B. Increased hair thinning
- C. Increased presence of fungal toenails
- D. Lesion with various colors
- E. Spider veins on legs
- F. Asymmetric 6-mm dark lesion on forehead
Correct Answer: D,F
Rationale: Skin lesions with various colors and an asymmetric 6-mm dark lesion fit two of the American Cancer Society's hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups.
A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder?
- A. Clean hair, skin, and nails
- B. Poor eye contact
- C. Disheveled appearance
- D. Drapes a scarf over the face
Correct Answer: A
Rationale: The nurse should complete a psychosocial assessment to determine if the client is coping effectively. Signs of adequate coping include clean hair, skin, and nails, good eye contact, and being socially active. A disheveled appearance and draping a scarf over the face to hide the client's appearance demonstrate that the client may not be coping effectively.
A nurse assesses a client who has open lesions. Which action should the nurse take first?
- A. Put on gloves.
- B. Ask the client about his or her occupation.
- C. Assess the clients pain.
- D. Obtain vital signs.
Correct Answer: A
Rationale: Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on.