The nurse is preparing a client for a detailed assessment of the integumentary system. Which statements by the nurse are useful to prepare the client for this examination?
Select all that apply.
1. "Please remove all jewelry so that I can conduct a full assessment."
2. "I will turn the temperature down in the exam room before we begin."
3. "Use this blanket to cover up until we are ready to begin."
4. "I will be touching your skin as part of the process."
5. "I will need you to take off your head dress for the entire examination."
Correct Answer: 1, 3, 4
Jewelry can often hinder the nurse's ability to conduct a complete skin assessment. This statement is appropriate to prepare the client for the exam. It is often necessary to expose certain areas of the skin during the assessment process. A drape should be provided to the client to cover all areas that are not being assessed. This action is appropriate prior to beginning the exam. Palpating the skin is part of an integumentary assessment. It is important to state this to the client before the examination. The temperature of the room should be warm, yet comfortable. Turning down the temperature without first asking the client's input is not appropriate. While it may be necessary for the client's head dress to be removed during certain portions of the exam, it is not necessary for the entire examination process. This statement does not take the client's cultural background into consideration and is not appropriate.
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