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24 - Chapter 24 Assessment of the Skin Hair and Nails...

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Chapter 24: Assessment of the Skin, Hair, and Nails Ignatavicius: Medical-Surgical Nursing, 8th Edition MULTIPLE CHOICE 1. While assessing a client, a nurse detects a bluish tinge to the client’s palms, soles, and mucous membranes. Which action should the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the client’s oxygen saturation. c. Auscultate the client’s lung fields for adventitious sounds. d. Palpate the client’s bilateral radial and pedal pulses. ANS: B Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments. DIF: Applying/Application REF: 422 KEY: Cyanosis MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition? a. “What do you do for a living?” b. “Are your nails professionally manicured?” c. “Do you have diabetes mellitus?” d. “Have you had a recent fungal infection?” ANS: A The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding. DIF: Applying/Application REF: 427 KEY: Infection MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. 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?” ANS: D 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.
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DIF: Applying/Application REF: 424 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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