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    Hesi rn health assessment proctored exam (retest)

    The nurse assesses a client's fingernails as seen in the photo. How should the nurse document the findings?

    Explanation & Rationale

    Rationale: A. Fingernail pitting present: Fingernail pitting appears as small depressions or pits on the nail surface, often seen in psoriasis. The client's nails in the photo are smooth and intact, showing no signs of pitting, so this option is not accurate. B. Nail care needed: Nail care would be documented if there were overgrown, broken, dirty, or neglected nails. The nails shown are clean and neatly maintained, meaning nail care is not an immediate need for this client. C. Capillary refill less than 3 seconds: Capillary refill time measures circulation but is not assessed just by observing nail color. It requires pressing the nail and timing how quickly color returns, which is not part of this static assessment. D. Nailbeds pink: Pink nailbeds indicate good peripheral circulation and oxygenation. In the photo, the client's nailbeds are visibly pink without cyanosis, discoloration, or pallor, making this the correct documentation of the findings.

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