The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

Oral mucosa

Palms

Sclera

Nail beds

Answer and Explanation

The Correct Answer is A

A. Oral mucosa is correct. Central cyanosis occurs when oxygen saturation is significantly reduced and is best assessed in areas with rich vascular supply, such as the oral mucosa, lips, and tongue.
B. Palms are incorrect because peripheral cyanosis (often due to cold exposure or poor circulation) can cause blue-tinged extremities, but this does not indicate central cyanosis.
C. Sclera is incorrect because cyanosis does not affect the sclera; however, jaundice does.
D. Nail beds are incorrect because, like the palms, they are more indicative of peripheral cyanosis, which can result from localized poor perfusion rather than central oxygenation problems.

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Correct Answer is D

Explanation

A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.

A. Review the client's blood work for sodium and bicarbonate levels. B. Assess the client for signs and symptoms of peptic ulcer disease. C. Assess the client's nutritional status. D. Assess the client for other signs and symptoms of liver disease.

Correct Answer is D

Explanation

A. Reviewing sodium and bicarbonate levels is not the most immediate action. While these lab values may provide useful information, they do not directly assess the suspected condition.
B. Assessing for peptic ulcer disease is incorrect because a tight, distended abdomen with visible arterioles (caput medusae) is more indicative of liver disease, such as cirrhosis or portal hypertension, rather than a gastric ulcer.
C. Assessing the client’s nutritional status may be important, but it is not the priority in this situation. Malnutrition can be a consequence of liver disease, but the nurse should first focus on identifying the underlying condition.
D. Assessing the client for other signs and symptoms of liver disease is correct. A distended abdomen and visible arterioles suggest possible ascites and portal hypertension, both of which are common in liver disease. Further assessment for jaundice, hepatic encephalopathy, or changes in liver enzyme levels would be appropriate.

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The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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