During a physical exam of the patient's nails, the nurse depresses the nail edge to blanch it, and then releases it. What is the nurse assessing with this technique?
1. Whether clubbing of the nail is present
2. How brittle the nails are
3. Whether the nail is well attached to the nail bed
4. Capillary refill
4
Rationale 1: Clubbing is assessed by looking at the angle of the nail bed.
Rationale 2: Brittle nails are diagnosed by looking at the distal plates of the nail to inspect for splitting and peeling.
Rationale 3: This technique does not assess how well the nail is attached to the nail bed.
Rationale 4: The nail plate is translucent. To determine capillary refill, the nail edge is depressed to blanch and then released. Capillary refill is usually documented as a brisk return of color, which is the normal response.
You might also like to view...
The nurse is reviewing the plan of care for a client with delirium. Which interventions will the nurse include in the care for this client? Select all that apply.
A) Apply arm restraints to prevent self harm B) Allow client to eat alone during mealtimes C) Provide a calm, well-lit environment D) Reduce sound in the client's room at night E) Avoid constant observation to increase autonomy and security
What common symptom do you expect to find in a patient with peptic ulcer disease?
a. Frequently vomiting bright red blood b. Burning gnawing pain between the navel and sternum c. Nausea with reflux before and after all meals d. Dark coffee-ground textured stools
The nurse is preparing to administer PRN medication to an anxious client of Japanese descent. The prescription reads, "Alprazolam (Xanax) 0.25-1.0 mg PO PRN." The best dose for the nurse to give initially is:
A) 0.25 mg B) 0.5 mg C) 0.75 mg D) 1.0 mg
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?
A) Second intercostal space, left sternal border B) Third intercostal space, left axillary line C) Fourth intercostal space, left sternal border D) Fifth intercostal space, left midclavicular line