How should the nurse assess for the presence of bruises in a client with dark skin who experienced blunt trauma to the right thigh?

A. Palpate for and compare the popliteal and pedal pulses in both distal extremities.
B. Compare the contour and skin color of the injured area with the same area on the left thigh.
C. Press a glass slide against the skin over the injured area and determine whether or not the skin blanches.
D. Use the back of the hand to compare the skin temperature on the area of trauma to the same area of the left thigh.


B
Bruises in clients with dark skin can be seen as darker areas of skin and palpated as slight swel-lings or irregular skin surfaces. Ask the client about pain when skin surfaces are touched lightly or palpated.

Nursing

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The nurse is caring for a client who is experiencing acute pain. Which action by the client, noted by the nurse during the assessment, is considered an associated symptom of pain?

1. Changing position 2. Crying 3. Grimacing 4. Vomiting

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a. dystonic ataxia. b. cerebellar ataxia. c. steppage gait. d. tabetic stamping.

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An older patient is experiencing significant weight loss and has poorly fitting dentures that cause severe oral sores. When preparing the plan of care, which intervention will be most beneficial to the patient?

A. Evaluating the need for assistive devices B. Serving meals in an attractive environment C. Offering assistance to eat D. Providing analgesics as needed

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