The nurse is examining a patient with dark skin. In assessing for pallor, at which of the following will it be best for the nurse to specifically look?
a. Lips and tongue
b. Skin creases and folds
c. Hard palate
d. Sclera
A
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A Pallor is more easily seen in a dark-skinned patient when assessing the conjunctiva, sclera, buccal mucosa, tongue, lips, nail beds, palms, and soles of feet.
B Skin creases and folds are darker than the rest of the body in the dark-skinned patient.
C The hard palate is not a good site to assess for colour changes such as pallor.
D The best site to inspect for jaundice, not pallor, is the sclera.
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A) Cirrhosis B) Renal failure C) Hepatitis D) Cardiovascular disease
The nurse is admitting a client to the medical unit with a diagnosis of chronic obstructive pulmonary disease (COPD). When should the nurse perform the assessment of the client?
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Fill in the blank(s) with the appropriate word(s).
An 8-year-old child asks how a blood pressure is taken. What would be the most appropriate response?
a. "This small machine will measure your systolic and diastolic pressure." b. "The armband will hug your arm and tell me how well your blood is going through your arm." c. "The armband will cut off your circulation for a while and then we can hear when it comes back." d. "When you are ill we need to know if your blood is still moving in your body."