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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.
B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."
C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.
D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.
Correct Answer is C
Explanation
A) Chronic pain: Chronic pain is defined as pain that lasts for an extended period, often longer than three months, and is usually associated with conditions that are ongoing or recurring. The client’s symptoms, including sudden-onset severe pain and accompanying acute symptoms like nausea and vomiting, do not align with the characteristics of chronic pain.
B) Intractable pain: Intractable pain refers to pain that is resistant to treatment and does not respond well to analgesics or other interventions. While the client's pain is severe, the sudden onset and associated symptoms suggest a specific acute process rather than a pain condition that is inherently resistant to treatment.
C) Acute pain: Acute pain is characterized by its sudden onset and typically corresponds to a specific injury or condition, often with accompanying physiological responses such as nausea and restlessness. The client’s severe pain rating of 10, along with nausea and vomiting, strongly indicates that they are experiencing acute pain, likely related to an underlying acute abdominal condition.
D) End-of-life pain: End-of-life pain usually occurs in patients with terminal illnesses and is often managed with palliative care strategies. The client’s sudden onset of severe pain and accompanying symptoms indicate a different situation, likely not related to a terminal condition.
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