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. Dimpled area above anus: This can be a sign of a pilonidal cyst, a condition where hair follicles become embedded under the skin.

B. Flap of tissue at sphincter: This could indicate haemorrhoids, swollen veins in the anus and rectum.

C. Hypotonic tone of the anal sphincter: Weak anal sphincter tone can lead to faecal incontinence.

D. Increased pigmentation and coarse skin: This is a normal finding, especially in adults. The perianal area can have a darker colour and thicker skin texture compared to other areas

A. Assess for the use of illicit drugs. B. Obtain a smoking history first. C. Evaluate vital signs and laboratory findings. D. Ask the parents to leave the room.

Correct Answer is D

Explanation

A. Assess for the use of illicit drugs. While assessing illicit drug use is important, it may not be the most crucial intervention during the initial health history-taking process.

B. Obtain a smoking history first. While obtaining a smoking history is important, it may not take precedence over other aspects of the health history, especially if there are more pressing concerns.

C. Evaluate vital signs and laboratory findings. While vital signs and laboratory findings are important components of the assessment, they are typically obtained after the health history has been completed.

D. Ask the parents to leave the room. Ensuring privacy and confidentiality is crucial during adolescent health assessments to encourage open communication and address sensitive issues. Asking the parents to leave the room allows the adolescent to speak freely about their health concerns without fear of judgment or disclosure to their parents.

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

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Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Correct Answer is D

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Correct Answer is D

Explanation

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