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Chapter 23: Problem 162

The nurse is assisting with a physical assessment on a 20 -year-old AfricanAmerican client with hemolytic anemia. Which area would be the best location for the nurse to assess skin color? A. Sclera of the eyes B. Soles of the feet C. Palms of the hands D. Roof of the mouth

Short Answer

Expert verified
Answer: D. Roof of the mouth

Step by step solution

01

Eliminate areas with higher pigmentation

In an African American client, it is crucial to assess skin color in areas with little pigmentation to have accurate results. So, options B (soles of the feet) and C (palms of the hands) can be eliminated since these areas are generally more pigmented in African American individuals.
02

Consider the impact of hemolytic anemia on the remaining locations

Now that we have ruled out options B and C, we need to evaluate whether the sclera of the eyes (option A) or the roof of the mouth (option D) would be a better spot to assess skin color in the context of hemolytic anemia. Hemolytic anemia can lead to jaundice, which is a yellowing of the skin and eyes due to the buildup of bilirubin in the blood, making the sclera less reliable for assessing skin color.
03

Select the best location to assess skin color

Based on the analysis above, the roof of the mouth (option D) is the most appropriate location to assess skin color in a 20-year-old African American client with hemolytic anemia. It has less pigmentation than other areas, and it is not affected by jaundice as much as the sclera of the eyes. So, the correct answer is: D. Roof of the mouth

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