A nurse, who is of German descent, was told to watch a newly admitted African American client for any signs of cyanosis or pallor. Which of the following actions should be taken by the nurse? (Select all that apply.)
a. Applying pressure to the nail bed and observing how quickly color returns
b. Asking the visiting family members to tell the nurse if they notice such signs
c. Checking the palms of the hands and the soles of the feet
d. Consistently checking the blood pressure and pulse rate every 15 minutes
e. Looking between the strands of hair on the head for evidence
f. Telling the nurse in charge of the floor to have someone else, preferably an African American nurse, care for the client
ANS: A, C
You might also like to view...
The client is recovering from orthopedic surgery on a fractured arm. The nurse realizes that skeletal muscles provide which of the following functions? Standard Text: Select all that apply
1. Provide a body framework 2. Provide movement 3. Maintain posture 4. Generate heat 5. Calcium storage
The nurse notes a client's neck veins are distended when sitting upright. This finding is indicative of which of these conditions?
a. ascites c. pulmonary hypertension b. decreased renal out-put d. right-sided heart failure
For the first 12 months of life, what is the most desirable food?
1. formula 2. cow's milk 3. human milk 4. fruit juice
A group of nurses disagrees about whether or not to make spirituality a part of the assessment. Which statement provides a compelling argument in favor of including spiritual assessment?
a. Research clearly demonstrates that spiritual interventions by nurses are a cost-effective practice. b. Accrediting organizations regard spiritual care as a patient right. c. Spirituality is better addressed by nurses than by clergy. d. Prayer consistently improves mental health outcomes.