During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?
Nail Beds
Sclera
Oral Mucosa
Palms
The Correct Answer is C
A. Nail Beds:
While peripheral cyanosis can cause bluish discoloration of the nail beds, central cyanosis is more indicative of systemic hypoxemia and is best assessed in areas with rich blood supply, such as the oral mucosa.
B. Sclera:
The sclera is more commonly used to assess for jaundice (yellowing) rather than cyanosis. Cyanosis is not typically visible in the sclera.
C. Oral Mucosa:
Central cyanosis is most accurately assessed in areas with high vascularization, such as the oral mucosa. This area provides a clear indication of oxygenation status and can reveal hypoxemia more reliably than peripheral sites.
D. Palms:
Similar to the nail beds, the palms can show signs of peripheral cyanosis but are not the primary site for assessing central cyanosis. The oral mucosa remains the best site for this assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Facial edema: Myxedema is a severe form of hypothyroidism that is often characterized by the accumulation of mucopolysaccharides in the skin and other tissues, leading to facial and peripheral edema. This is a classic symptom of myxedema and is expected in clients with this condition.
B) Diarrhea: Diarrhea is more commonly associated with hyperthyroidism rather than hypothyroidism. Clients with myxedema typically experience constipation due to slowed gastrointestinal motility.
C) Tachycardia: Tachycardia is associated with hyperthyroidism. In contrast, myxedema is associated with bradycardia or a slow heart rate because of the overall slowing of the body's metabolic processes.
D) Heat intolerance: Heat intolerance is a symptom of hyperthyroidism. Clients with myxedema usually experience cold intolerance due to decreased metabolic activity and impaired thermoregulation.
Correct Answer is B
Explanation
A) Color discrimination:
Color discrimination involves assessing the client's ability to differentiate between various colors, typically using color plates like the Ishihara test. This test is often used to detect color blindness or deficiencies in color vision. The action depicted in the image, which involves reading text up close, is not relevant to assessing color vision capabilities.
B) Near vision:
Near vision is assessed by having the client read small text or print held at a close distance, often using a near vision chart or card. The image shows the client covering one eye with an occluder while reading text, which is a common method to test the clarity and focus of near vision. This helps determine if the client has issues such as presbyopia, which affects near vision acuity.
C) Distance vision:
Distance vision is typically evaluated using a Snellen chart, where the client reads letters or symbols from a distance of 20 feet. The test aims to assess the clarity of vision at a distance. The action in the image does not align with this type of assessment, as it focuses on close-up reading rather than distance.
D) Intraocular pressure:
Intraocular pressure is measured using tools like a tonometer to assess the fluid pressure inside the eye, which is crucial for diagnosing conditions like glaucoma. This test involves specific instruments and procedures, unlike the reading task depicted in the image, which is unrelated to measuring eye pressure.
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