A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?
Conjunctiva
Sclera of the eye
Back of the neck
Palms of the hands
The Correct Answer is B
Choice A Reason:
The conjunctiva can sometimes appear yellow in individuals with jaundice; however, it is not the most reliable area to inspect for jaundice. The conjunctiva may be affected by other factors such as environmental irritants or infections, which can alter its appearance.
Choice B Reason:
The sclera of the eye is the most reliable area to inspect for jaundice. The yellowing of the sclera, also known as scleral icterus, is a key indicator of jaundice. The sclera's white background provides a clear contrast, making any yellow discoloration more noticeable. This is particularly true in darker-skinned individuals, where skin changes may be less apparent.
Choice C Reason:
The back of the neck is not a reliable area to inspect for jaundice. Skin pigmentation and lighting can affect the visibility of yellowing, making it an unreliable indicator. Additionally, the back of the neck may have other skin changes unrelated to jaundice that could confuse the assessment.
Choice D Reason:
The palms of the hands are not the most reliable area to inspect for jaundice. While the palms may show yellowing, they are subject to various external factors such as manual labor or exposure to substances that can affect their color. Moreover, the palms' skin may be thicker and less transparent, making subtle changes in color more difficult to detect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Family History is used to document health events in the patient's family, including diseases that may be hereditary or place the patient at risk. The statement about feeling like an elephant is sitting on the chest is not related to family health but is a description of the patient's current symptoms.
Choice B Reason:
Past Medical History includes information about the patient's past health issues, surgeries, hospitalizations, allergies, and treatments. It does not include current symptoms or the reasons for the current hospital visit.
Choice C Reason:
The Chief Complaint is the section where the nurse documents the primary reason for the patient's visit in their own words. The phrase "feels like an elephant is sitting on his chest" is a classic description of chest pain or discomfort, often associated with cardiac issues, and would be documented here as it represents the patient's main concern.
Choice D Reason:
Present Illness or History of Present Illness would include a detailed account of the development of the patient's illness or health concern. While it is closely related to the Chief Complaint, it is more detailed and includes the onset, duration, and character of the symptoms, among other aspects. The initial statement would be part of the Chief Complaint, which leads into the more detailed History of Present Illness.
Correct Answer is A
Explanation
Choice a reason:
A BMI of 27 falls into the 'Overweight' category according to the standard BMI classification. The 'Overweight' range is defined as a BMI of 25 to 29.9. This indicates that the person's weight is higher than what is considered healthy for a given height.
Choice b reason:
'Obesity Class I' is characterized by a BMI of 30 to 34.9. Since the client's BMI is 27, it does not reach the threshold for this category.
Choice c reason:
The 'Normal weight' category ranges from a BMI of 18.5 to 24.9. With a BMI of 27, the client exceeds the upper limit of the normal weight range.
Choice d reason:
The term 'Obesity' generally refers to a BMI of 30 or higher, which encompasses Obesity Class I, II, and III. Since the client's BMI is 27, it is below the obesity range.
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