The client with darkly pigmented skin is on bed rest. Which client assessment does the nurse monitor for an early indication of a pressure ulcer? (Select all that apply.)
1. Skin irritation
2. Dull, tight area
3. Regional edema
4. Regional induration
5. Darkened skin color
6. Increased temperature
3, 4, 5
3, 4, and 5. Early detection of pressure ulcers for a client with dark skin is proble-matic because initial skin changes are difficult to distinguish. Characteristics of im-paired skin integrity for clients with dark skin include regional edema, induration, and changes in skin color, especially skin darkening or areas of purplish or bluish tones as cells begin to exhibit clinical indications of hypoxia.
1 and 6. Skin irritation and an increased temperature are nonspecific clinical indica-tors and are consistent with many disorders, including inflammation, infection, aller-gy, dehydration, and drug reactions.
2. Taut skin is characteristic of a developing pressure ulcer for a client with dark skin; however, the tissue is usually shiny.
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A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim?
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The umbilical vein carries
A. Carbon dioxide from the fetus back to the placenta B. Deoxygenated blood from the fetus to the placenta C. Oxygenated blood from the placenta to the fetus