The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

"Please remove all jewellery so that I can conduct a full assessment."

"I will be touching your skin as part of the process."

"I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin."

"I will need you to take off your head dress for the entire examination."

Answer and Explanation

Correct Answer : A,B,D

For a thorough assessment of the integumentary system, the nurse should provide the following instructions:

A. "Please remove all jewellery so that I can conduct a full assessment."

This is correct. Jewelry can obstruct the assessment of skin, especially in areas like the neck, chest, and hands, where it may cover or hide skin abnormalities.

B. "I will be touching your skin as part of the process."

This is correct. A thorough integumentary assessment involves palpating the skin to check for texture, moisture, temperature, and other characteristics. It's important for the client to be informed that touch will be involved.

C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin."

This is partially correct. The temperature in the exam room should be comfortable, but turning it down may not be necessary. The instruction to cover with a blanket is appropriate to preserve the client's privacy and warmth until the assessment begins.

D. "I will need you to take off your head dress for the entire examination."

This is correct. If the head dress covers the scalp or areas that need to be examined (like the scalp, ears, or face), it should be removed to allow for a full assessment of the integumentary system.

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Correct Answer is A

Explanation

A) Subjective report: The most reliable indicator of pain is the patient's own description of their experience. Pain is inherently subjective, and individuals may perceive and express pain differently. Listening to the client's self-report provides valuable insight into their pain intensity, quality, and impact on daily life, which cannot be accurately assessed through objective measures alone.

B) Physical exam: While a physical exam can provide important information about potential sources of pain or related conditions, it may not accurately reflect the intensity or nature of the pain the patient is experiencing. Physical findings may vary widely among individuals with similar pain complaints, making this a less reliable indicator.

C) Results of a CAT scan: Imaging studies like CAT scans can identify structural issues, such as fractures or tumors, but they do not measure pain. Many patients with significant pain may have normal imaging results, while others with severe findings may report minimal discomfort, underscoring the limitations of relying solely on diagnostic tests.

D) The client's vital signs: Vital signs can indicate physiological responses to pain, such as increased heart rate or blood pressure, but they are not specific indicators of pain severity. Many factors can influence vital signs, including anxiety and other medical conditions, making them unreliable for assessing pain levels independently.

A. Listen for another minute just to be sure B. Contact the physician as this is a surgical emergency. C. Auscultate for another 4 minutes D. Listen posteriorly for enhanced bowel sounds

Correct Answer is C

Explanation

A) Listen for another minute just to be sure: While it is important to confirm findings, simply listening for another minute may not provide enough time to accurately assess bowel sounds, as they can be infrequent or absent in certain conditions.

B) Contact the physician as this is a surgical emergency: Not hearing bowel sounds for a minute is not immediately indicative of a surgical emergency. It’s essential to gather more information before escalating the situation.

C) Auscultate for another 4 minutes: This is the appropriate action, as the nurse should auscultate for a total of 5 minutes (1 minute initially and then 4 more minutes) to adequately assess bowel sounds. This duration allows for the detection of normal, hypoactive, or absent bowel sounds, which can provide critical information about the client’s gastrointestinal function.

D) Listen posteriorly for enhanced bowel sounds: While listening from different positions may sometimes help, the standard practice is to listen for an appropriate duration before changing techniques. Auscultating for a longer period is more clinically relevant in this scenario.

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The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the most reliable indicator of pain?

Correct Answer is A

Explanation

The nurse auscultates the client's abdomen for 1 minute and does not hear anybowel sounds. What should the nurse do next?

Correct Answer is C

Explanation

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