A nurse is performing a head to toe assessment on a client. Which of the following assessment findings would the nurse recognize as requiring an immediate action and would be the first priority when addressing a patient health problem?
Pallor.
Jaundice.
C. Cyanosis.
Erythema.
The Correct Answer is C
The correct answer is choice C. Cyanosis. Cyanosis is a medical emergency and requires immediate action by the nurse. It indicates that the client is not receiving adequate oxygenation and can lead to respiratory failure if not addressed promptly. Pallor (Option A) and erythema (Option D) are concerning but are not immediate priorities compared to cyanosis. Jaundice (Option B) may indicate liver dysfunction but is not an immediate priority unless it is associated with other symptoms such as severe abdominal pain or altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The rationale for self-care that the nurse should communicate to the client's family is that the client's sense of loss can be lessened through retaining dignity and control of certain areas of their life such as ADLs. Allowing the client to perform self-care activities independently, to the extent possible, promotes the client's autonomy and helps to preserve their selfesteem and sense of control over their life. As the client nears the end of life, it is important to respect their wishes and promote their comfort and well-being in every way possible.
Correct Answer is C
Explanation
The correct answer is choice C: Skin fold returns to its usual shape quickly when released. When assessing skin turgor, the nurse is checking for the elasticity and hydration of the skin. In a normal assessment, when the skin fold is lifted or pinched, it should return to its usual shape quickly when released. This indicates good skin turgor, which is an indication of proper hydration. If the skin fold is difficult to lift or pinch (choice A), this indicates poor skin turgor and possible dehydration. If an indentation of 2 mm remains after releasing the skin fold (choice B), this indicates poor skin turgor and possible dehydration. If the skin fold returns to its usual shape slowly when released (choice D), this may indicate a decrease in skin elasticity and possible dehydration.
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