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) Obtain a height and weight and calculate a body mass index (BMI): Calculating BMI provides a valuable assessment of a patient’s body composition and overall health related to dietary habits. BMI is a widely used indicator that helps categorize individuals into underweight, normal weight, overweight, and obese categories. Understanding where a patient falls within these categories can highlight the potential impact of dietary habits on health and guide further dietary interventions or education.
B) Review all medications the patient is taking: While reviewing medications is important, it primarily focuses on pharmacological management rather than directly assessing dietary habits. Some medications may have dietary restrictions or require specific nutrient intake, but this does not provide a comprehensive view of the patient's overall dietary habits and their effects on health.
C) Ask about how much food is eaten at an average meal: While inquiring about portion sizes is relevant, it does not give a full picture of dietary habits, including food variety, nutrient quality, and frequency of meals or snacks. A single question about average meal size may overlook other critical aspects of the patient’s eating patterns and nutritional intake.
D) Assess for the presence of any chronic disease processes: Evaluating chronic diseases is crucial for understanding health implications, but it does not directly assess dietary habits. Chronic conditions can be influenced by diet, but the assessment of dietary habits requires a more direct inquiry into nutritional intake and lifestyle choices rather than focusing solely on disease presence.
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.