The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

Blue tinge in the nail beds.

Ashen grey tone to lips.

Ashy yellow appearance of skin.

Reddish purple colored palms.

Answer and Explanation

The Correct Answer is A

A. Blue tinge in the nail beds: This finding is indicative of cyanosis. When oxygen levels in the blood are low, the skin and mucous membranes may appear bluish due to inadequate oxygenation. The nail beds are a common area to observe this bluish discoloration.

B. Ashen grey tone to lips: While this can be concerning, it is not a classic sign of cyanosis. Ashen grey lips may be associated with other conditions, such as shock or poor perfusion, but they do not specifically indicate cyanosis.

C. Ashy yellow appearance of skin: This finding is not related to cyanosis. An ashy yellow appearance may be seen in conditions like liver disease or jaundice, but it does not reflect oxygenation status.

D. Reddish purple colored palms: Again, this is not a sign of cyanosis. Reddish or purple palms may be seen in various conditions, but they do not specifically point to inadequate oxygen levels.

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Correct Answer is D

Explanation

A. Allow the client to compose herself then change the subject.

This response allows the client some time to regain composure, which can be helpful. However, abruptly changing the subject may make the client feel dismissed or unheard. It's essential to address the emotional response with sensitivity.

B. "Why don't I come back in a few minutes after you are more composed."

While this response acknowledges the client's emotional state, it may unintentionally communicate a lack of availability or willingness to support the client in that moment. It's important for the nurse to offer support and empathy immediately rather than suggesting a delay.

C. "I'm so sorry that I made you cry. I didn't mean to upset you."

This response acknowledges the client's emotional response and expresses empathy, which is a crucial aspect of providing patient-centered care. However, it's important to avoid taking personal responsibility for the client's emotional reaction, as it may not have been caused solely by the nurse's questions.

D. Offer a tissue and sit quietly until the crying subsides.

This response demonstrates empathy and support by providing a tissue and offering a non-verbal gesture of comfort. Sitting quietly allows the client the space to express her emotions while feeling supported by the nurse's presence.

A. Takes an oral anticoagulant. B. Works in a day care center. C. Adheres to a gluten free diet. D. Recently had dental surgery.

Correct Answer is A

Explanation

A. Takes an oral anticoagulant. Ecchymosis, or bruising, can be a side effect of anticoagulant therapy and may indicate potential bleeding issues that require further assessment.

B. Works in a day care centre. While exposure to children might increase the risk of minor injuries, it is less likely to be directly related to the ecchymosis observed.

C. Adheres to a gluten-free diet. This dietary preference is not likely to be directly related to the ecchymosis observed.

D. Recently had dental surgery. While recent surgery might be relevant, it is less likely to cause widespread ecchymosis unless there were complications.

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The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is A

Explanation

Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

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