The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.
Texture
Tachypnea
Turgor
Temperature
Tympany
Correct Answer : A,C,D
A) Texture: Assessing the texture of the skin is an important part of a comprehensive skin assessment. It provides insights into the health and hydration status of the skin. Normal skin texture should feel smooth and even, while changes can indicate issues such as dryness or conditions like eczema or psoriasis.
B) Tachypnea: This term refers to an increased respiratory rate and is not a characteristic assessed in the skin. While it can indicate a physiological response to various conditions, it does not relate to skin health or characteristics and therefore is not relevant in this context.
C) Turgor: Skin turgor refers to the elasticity and hydration status of the skin, which can be assessed by pinching the skin. Proper turgor indicates adequate hydration, while decreased turgor can signal dehydration or other health issues. This is an essential component of skin assessment.
D) Temperature: Assessing the temperature of the skin can provide information about circulation and potential inflammation or infection. Normal skin temperature should feel warm and consistent, while variations can suggest underlying conditions such as fever or shock.
E) Tympany: Tympany is a term used in percussion assessments of the abdomen and is not applicable to skin assessment. It refers to a hollow sound produced by tapping on a body surface and does not pertain to skin characteristics.
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Correct Answer is A
Explanation
A) "What can we do to accommodate your needs during your stay here?" This response is the most appropriate as it demonstrates cultural sensitivity and respect for the client’s religious practices. It opens the door for a collaborative discussion about how the healthcare team can support the client’s fasting while ensuring that his health needs are met during hospitalization.
B) "I will let your healthcare provider know that you need to be discharged." While it is important to communicate the client’s needs to the healthcare provider, suggesting discharge may not be a feasible solution. It does not address the complexities of fasting during hospitalization and could imply that the client’s faith is a burden rather than a respected aspect of their care.
C) "Fasting may be harmful to your body during your illness." While it is crucial to ensure the client’s health is not compromised, this response could come off as dismissive of the client’s beliefs. Instead of expressing concern, it could be more beneficial to explore how fasting can be managed within the context of their medical care.
D) "You must eat a high protein diet during times of illness." This response does not take into account the client’s religious beliefs and fails to respect the significance of fasting in the Muslim faith. While dietary considerations are important, this approach disregards the client’s right to practice their faith and may come across as prescriptive rather than collaborative.
Correct Answer is D
Explanation
A) The patient has asthma: While asthma can lead to respiratory symptoms and issues, it is not typically associated with clubbing of the fingernails. Asthma primarily affects airway constriction and inflammation, rather than causing the long-term changes in nail morphology seen with clubbing.
B) The patient has cardiovascular disease: Although some cardiovascular conditions can lead to clubbing, it is more commonly associated with chronic lung diseases. Cardiovascular disease might cause other signs or symptoms, but clubbing alone is not a definitive indicator of this condition.
C) The patient has emphysema: Emphysema, a type of chronic obstructive pulmonary disease (COPD), is characterized by the destruction of lung tissue and impaired airflow. While it can contribute to hypoxemia, clubbing is not a common finding specifically associated with emphysema.
D) The patient has chronic hypoxemia: Clubbing of the fingernails is a classic sign of chronic hypoxemia, often resulting from long-term respiratory conditions like COPD, interstitial lung disease, or lung cancer. It indicates a prolonged lack of oxygen in the blood, leading to changes in the nail bed and digit shape. Given the patient's long smoking history, chronic hypoxemia is the most likely explanation for this finding.