A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete?

A. Wear gloves only if the skin appears broken or inflamed. Gloves should be worn to protect both the patient and the nurse from infection regardless of the appearance of the skin.
B. Ask the patient about personal skin care. Understanding the patient's personal skin care practices can provide insight into potential issues and areas needing attention.
C. Avoid potentially embarrassing questions about rashes or scars. Addressing rashes or scars is crucial for proper assessment and treatment, despite potential embarrassment.
D. Have artificial, preferably fluorescent, lighting for proper illumination of the skin. Proper lighting is important, but asking about personal skin care can provide additional context and help with a thorough assessment.

A. Very disruptive to a person in society: This description is judgmental and not specific to documenting behavior objectively.

B. Differing from socially acceptable behavior: Documenting behavior as differing from socially acceptable norms provides an objective, non-judgmental account of the patient’s behavior.

C. Causing the person to be involved in problems: This focuses on the outcomes of the behavior rather than describing the behavior itself.

D. Resulting from an inability to exercise control: This may imply a lack of control but does not objectively describe the behavior for documentation purposes.