During a skin assessment, the nurse notes a blue discoloration of the client's lips and nail beds. How should the nurse interpret this finding?
Age-related skin change
Possible hypoxia
Normal finding in darker skin tones
Expected response to heat exposure
The Correct Answer is B
Rationale:
A. Age-related skin changes typically include thinning, dryness, wrinkles, and decreased elasticity. They do not cause blue discoloration (cyanosis) of the lips and nail beds. Therefore, this finding is not considered a normal age-related change.
B. Blue discoloration of the lips and nail beds, known as cyanosis, indicates possible hypoxia, meaning the body’s tissues may not be receiving adequate oxygen. This is a clinical sign that requires prompt assessment and intervention to identify the underlying cause and prevent complications.
C. While individuals with darker skin tones may have variations in skin pigmentation, cyanosis is still detectable on the lips, tongue, nail beds, and mucous membranes. It is not considered a normal baseline finding in darker skin; a bluish tint in these areas should always prompt evaluation for hypoxia.
D. Exposure to heat typically causes vasodilation, which can result in redness, warmth, or flushing of the skin. It does not cause blue discoloration, so this finding is not consistent with a response to heat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Step 1: Identify desired dose and concentration
Desired dose = 30 mg, Concentration = 50 mg/1 mL
Step 2: Use the formula
Volume (mL) = Desired dose ÷ Concentration
Step 3: Insert values
= 30 ÷ 50
Step 4: Calculate
= 0.6 mL
Step 5: Round to the nearest tenth
≈ 0.6 mL
Final Answer: 0.6
Correct Answer is C
Explanation
Rationale:
A. Decreased serum calcium affects bone health and may lead to osteoporosis or muscle weakness, but it is not a direct factor in the development of pressure injuries. While poor calcium levels may indirectly affect mobility, pressure injuries are primarily caused by localized tissue ischemia rather than systemic calcium deficiencies.
B. Increased muscle mass actually provides more padding over bony prominences, which helps protect against pressure injury. Clients with well-developed musculature are generally at lower risk compared with those who have muscle wasting or atrophy.
C. Decreased circulation is a primary risk factor for pressure injury development. Impaired blood flow reduces oxygen and nutrient delivery to tissues, making skin and subcutaneous tissue more susceptible to ischemia and necrosis when exposed to prolonged pressure, friction, or shear. Clients with impaired mobility are especially vulnerable because they cannot shift positions effectively to relieve pressure.
D. Increased collagen strengthens connective tissue and promotes skin integrity. While insufficient or abnormal collagen can contribute to skin breakdown, increased collagen alone does not predispose a client to pressure injuries and is generally protective rather than harmful.
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