When performing a physical assessment of the patient's skin, which principle should guide the nurse?
Use layman's terms when reporting or documenting.
Compare symmetric parts.
Inspect specific lesions before performing a generalized examination of the skin.
Palpate the temperature of the skin with the fingertips.
The Correct Answer is B
Choice A rationale
Using layman's terms in reporting or documenting patient assessments is inappropriate in a scientific and professional healthcare setting. Medical documentation requires precise, standardized medical terminology to ensure clarity, accuracy, and consistent communication among healthcare professionals, maintaining a high standard of care.
Choice B rationale
Comparing symmetric body parts is a fundamental principle in skin assessment. This allows the nurse to identify subtle differences, such as variations in color, texture, temperature, or the presence of lesions, by using the unaffected side as a baseline for comparison. This systematic approach enhances the accuracy of the assessment.
Choice C rationale
A generalized examination of the skin should precede the inspection of specific lesions. This systematic approach allows the nurse to gain an overall understanding of the patient's skin condition before focusing on particular areas of concern. This prevents overlooking other significant findings and provides a comprehensive assessment.
Choice D rationale
Palpating the temperature of the skin with the fingertips is less accurate than using the dorsal (back) surface of the hand. The dorsal surface has thinner skin and more temperature receptors, making it more sensitive to subtle temperature variations, which is crucial for detecting localized inflammation or circulatory changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Bright red blood in the urine, especially in large amounts or clots, after a cystoscopy is an abnormal finding. While some pink-tinged urine is expected, significant bright red bleeding can indicate hemorrhage or bladder wall injury requiring immediate medical intervention to prevent complications.
Choice B rationale
Urinary frequency is a common and expected finding after a cystoscopy due to irritation of the bladder mucosa from the procedure. This typically resolves within a day or two as the bladder recovers from instrumentation.
Choice C rationale
Pink-tinged urine is considered a normal and expected finding after a cystoscopy. The procedure involves instrumentation of the urethra and bladder, which can cause minor trauma to the mucosal lining, leading to a small amount of blood in the urine.
Choice D rationale
Burning on urination, also known as dysuria, is a common and expected sensation after a cystoscopy due to irritation and inflammation of the urethra and bladder from the scope. This discomfort usually subsides within 24 to 48 hours.
Correct Answer is B
Explanation
Choice A rationale
As individuals age, the kidneys' ability to concentrate urine declines due to structural and functional changes in the renal tubules and collecting ducts, including decreased response to antidiuretic hormone. This diminished concentrating ability often leads to an increased excretion of dilute urine, rather than enhanced concentration.
Choice B rationale
Normal physiological changes of aging affecting the urinary system include decreased bladder capacity, decreased bladder muscle tone, and increased involuntary bladder contractions. These changes often result in symptoms such as urinary frequency (more frequent voiding), urgency (sudden strong urge to void), and nocturia (waking up at night to urinate).
Choice C rationale
In healthy adults, the kidneys are typically not easily palpable unless they are enlarged due to pathology, such as polycystic kidney disease or hydronephrosis. Normal kidneys are protected by the lower ribs and posterior abdominal muscles, making deep palpation challenging for identification of normal size.
Choice D rationale
While some older adults may experience increased urinary incontinence due to age-related changes or comorbidities, it is not an inevitable outcome of aging that all patients will require wearing a brief at all times. Many older adults maintain continence with proper management, exercise, and lifestyle modifications, thus avoiding dependence on briefs.
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