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 B
Explanation
A. This term suggests a problem with blood flow, which could potentially cause symptoms such as numbness or tingling. However, it does not specifically address the sensation of burning. Using this term might lead to an incorrect or incomplete assessment of the client's condition.
B. Paresthesia is a term used to describe abnormal sensations in the skin, such as burning, tingling, or prickling. The client's report of a burning sensation in the hands and legs aligns well with the definition of paresthesia. Documenting it as "paresthesia reported" accurately reflects the nature of the symptoms and is a medically precise way to describe the abnormal sensory experience.
C. This documentation uses colloquial language ("on fire") to describe the client's symptoms. While it conveys the intensity of the sensation, it is not a standardized medical term and may not be as clear or useful for clinical documentation.
D. Inflammation refers to the body's response to injury or infection, which often involves redness, swelling, heat, and pain. The term "inflammation" does not specifically describe the sensation of burning reported by the client.
Correct Answer is A
Explanation
A. Nailbed clubbing is characterized by an increased angle between the nail and the nailbed, typically greater than 180 degrees. An angle of 200 degrees is consistent with clubbing, which can be a sign of chronic respiratory or cardiovascular conditions, such as chronic lung diseases, congenital heart defects, or other systemic conditions.
B. Consulting with a podiatrist to trim toenails is important for foot care but is not directly related to the finding of nailbed clubbing. The angle of the nailbed is more indicative of a systemic issue rather than a local foot care problem. Therefore, this action does not address the underlying concern suggested by the angle of 200 degrees.
C. While anemia or other blood conditions can affect the nails, the specific finding of a nailbed angle of 200 degrees is more indicative of clubbing rather than issues typically associated with hemoglobin levels. Therefore, while monitoring hemoglobin is important for overall health, it is not the immediate priority in response to the finding of nailbed clubbing.
D. Administering oxygen might be necessary if the client is experiencing symptoms of hypoxia or has a condition affecting oxygenation. However, the finding of nailbed clubbing itself does not immediately necessitate oxygen therapy. Oxygen administration should be based on specific symptoms or clinical indications of hypoxia rather than the nailbed angle alone.
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