When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?
Measure the degree of skin elasticity.
Palpate the area for warmth and swelling.
Determine the client's oxygen saturation.
Observe the appearance of the nailbeds.
The Correct Answer is B
A. Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B. Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C. Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D. Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The numeric pain intensity scale is a direct and effective method to assess the level of pain a patient is experiencing. If a client is splinting their chest, it’s essential to evaluate their pain level to determine the severity and guide appropriate pain management strategies. This is likely the most relevant and immediate follow-up assessment in this scenario.
B. An apical-radial pulse deficit measures the difference between the apical pulse (heart rate auscultated at the apex of the heart) and the radial pulse (heart rate palpated at the wrist). This assessment is used to detect conditions such as atrial fibrillation or other arrhythmias and is not directly related to the client’s chest splinting. Therefore, it is not the most relevant follow-up assessment in this context.
C. The anteroposterior (AP) chest diameter assessment is used to evaluate conditions such as barrel chest, which can be associated with chronic respiratory conditions. While this measurement can be important for assessing chronic respiratory issues, it is not directly related to the immediate concern of chest splinting, which is more likely associated with acute pain or discomfort.
D. Measuring body temperature is important for assessing the presence of fever or infection, but it does not directly address the client’s immediate complaint of chest pain or discomfort. While an elevated temperature might be relevant if an infection is suspected, it is not the most direct or immediate follow- up assessment for the observed behavior of splinting the chest.
Correct Answer is D
Explanation
A. Cloudy discharge is more commonly associated with infections or discharge from the genital area rather than residual urinary symptoms. While urinary tract infections (UTIs) can cause cloudy urine, this is not typically associated with suprapubic tenderness or the sensation of residual pressure alone.
B. An overactive bladder is characterized by symptoms such as frequent urination, urgency, and sometimes incontinence. However, it does not typically cause suprapubic tenderness or a sensation of residual pressure after urination. The described symptoms are more consistent with bladder outlet obstruction or incomplete bladder emptying rather than an overactive bladder.
C. Black tarry stools indicate upper gastrointestinal bleeding and are unrelated to urinary symptoms. This finding would suggest a different issue entirely, such as gastrointestinal bleeding, rather than a problem with the urinary tract or bladder. This is not consistent with the client's reported symptoms of suprapubic tenderness and sensation of residual pressure after urination.
D. A weak urinary stream is a common symptom associated with bladder outlet obstruction or conditions affecting urinary flow, such as benign prostatic hyperplasia (BPH) in older men. This finding aligns with the client's reported symptoms of suprapubic tenderness and feeling of residual pressure after urination.
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