The nurse assesses a client's fingernails as seen in the photo. How should the nurse document the findings?

Fingernail pitting present.

Nail care needed.

Capillary refill less than 3 seconds.

Nailbeds pink.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Fingernail pitting present: Fingernail pitting appears as small depressions or pits on the nail surface, often seen in psoriasis. The client's nails in the photo are smooth and intact, showing no signs of pitting, so this option is not accurate.

B. Nail care needed: Nail care would be documented if there were overgrown, broken, dirty, or neglected nails. The nails shown are clean and neatly maintained, meaning nail care is not an immediate need for this client.

C. Capillary refill less than 3 seconds: Capillary refill time measures circulation but is not assessed just by observing nail color. It requires pressing the nail and timing how quickly color returns, which is not part of this static assessment.

D. Nailbeds pink: Pink nailbeds indicate good peripheral circulation and oxygenation. In the photo, the client's nailbeds are visibly pink without cyanosis, discoloration, or pallor, making this the correct documentation of the findings.

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Correct Answer is A

Explanation

Rationale:
A. Palpate the area for warmth and swelling: Erythema, or redness of the skin, can indicate inflammation, infection, or irritation. Palpating the area for warmth and swelling helps assess for signs of underlying infection, cellulitis, or inflammatory response, providing critical information to guide further management.

B. Measure the degree of skin elasticity: Skin elasticity assessment, such as testing for turgor, is useful for evaluating hydration status. However, it is unrelated to erythema and does not help determine the underlying cause or severity of the redness observed.

C. Determine the client's oxygen saturation: Oxygen saturation is important for assessing respiratory and circulatory function but does not directly relate to localized erythema. Erythema usually results from localized skin or tissue changes, not systemic hypoxemia.

D. Observe the appearance of the nailbeds: Observing nailbeds can help assess systemic perfusion and oxygenation issues like cyanosis, but it does not provide specific information about localized redness or inflammation in an area like the arm where erythema is present.

A. Numeric pain intensity scale. B. Apical-radial pulse deficit. C. Anteroposterior (AP) chest diameter. D. Body temperature.

Correct Answer is A

Explanation

Rationale:
A. Numeric pain intensity scale: Splinting the chest with a pillow is a common behavioral sign of chest pain or discomfort, often due to surgical incisions, musculoskeletal strain, or cardiac issues. Assessing the client's pain using a numeric scale provides crucial information for guiding pain management and further diagnostic evaluation.

B. Apical-radial pulse deficit: An apical-radial pulse deficit is useful for detecting cardiac arrhythmias, but it is not the immediate priority based on the client's behavior. Addressing the possible cause of splinting, likely pain, should come first before assessing for pulse discrepancies.

C. Anteroposterior (AP) chest diameter: Measuring AP chest diameter helps assess chronic lung conditions such as barrel chest in emphysema. However, this measurement does not address acute signs of pain or discomfort indicated by chest splinting.

D. Body temperature: Checking temperature can help detect infection or fever but is not the most relevant initial assessment when a client is demonstrating behaviors specifically suggestive of chest pain. Pain assessment should take precedence in this context.

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The nurse assesses a client's fingernails as seen in the photo. How should the nurse document the findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow up assessment should the nurse complete?

Correct Answer is A

Explanation

When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow up assessment should the nurse complete?

Correct Answer is A

Explanation

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