A nurse is assessing a client who has asthma.
Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

The correct answer is Choice C.

Choice A rationale

Puberty might be delayed if scrotal changes have not occurred by the age of 13½ to 14 years, not 11 years.

Choice B rationale

Changes in the voice occur during puberty but do not signal its beginning. Enlargement of the testicles is the first sign of puberty in boys.

Choice C rationale

Growth spurts in height typically occur toward the end of mid-puberty, making this the correct answer.

Choice D rationale

Gynecomastia, or the development of breast tissue in boys, commonly occurs during mid- puberty, not late puberty. .

The correct answer is Choice A.

Choice A rationale

Increased crying episodes are a common indicator of pain in infants. Crying is a behavioral response to discomfort and can be more intense or frequent when the infant is in pain. This response is due to the activation of the infant’s nervous system, which signals distress through crying.

Choice B rationale

Decreased respiratory rate is not typically associated with pain in infants. Pain usually causes an increase in respiratory rate due to the body’s stress response, which involves the release of adrenaline and other stress hormones that stimulate the respiratory system.

Choice C rationale

Decreased heart rate is also not a common sign of pain in infants. Pain generally leads to an increased heart rate as part of the body’s fight-or-flight response, which is mediated by the sympathetic nervous system.

Choice D rationale

Increased formula consumption is not an indicator of pain. In fact, pain might reduce an infant’s appetite and lead to decreased feeding. Pain can cause discomfort during feeding, leading to fussiness and refusal to eat.