The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Wash hands
Provide patient privacy
Obtain a provider healthcare order
Position the client comfortably on the sturdy examination table
Explain the procedure to the client
Correct Answer : A,B,D,E
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
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Correct Answer is D
Explanation
A. Bradypnea (slow breathing) may occur in various conditions but is not a defining characteristic of cyanosis.
B. A pale reddish color in the skin is not consistent with cyanosis, which indicates a lack of oxygen in the blood.
C. Somnolence (drowsiness) may be present in some patients, but it is not a specific finding related to cyanosis.
D. Mottled blue color in the skin is a classic sign of cyanosis, indicating inadequate oxygenation of the blood, especially in the extremities or areas with poor circulation.
Correct Answer is ["B","D","E","F"]
Explanation
A. Hypoactive oil and sweat glands: Pregnancy typically causes increased activity in oil and sweat glands, not decreased.
B. Increased skin pigmentation: Increased pigmentation is common during pregnancy, often affecting areas like the areolas and abdomen.
C. Persistent migraine headaches: While some women may experience headaches in pregnancy, they are not an expected or typical finding and may require further assessment.
D. Facial edema: Mild facial edema can occur as pregnancy progresses, especially due to increased blood volume and fluid retention.
E. Melasma: Melasma, or "mask of pregnancy," is a common finding characterized by dark patches on the face due to hormonal changes.
F. Linea nigra: Linea nigra is a dark line that often appears on the abdomen during pregnancy as a result of hormonal changes.