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 C

Explanation

A. Delaying follow-up for two weeks is inappropriate when symptoms suggest a possible serious metabolic disorder, such as diabetes. Immediate testing is needed.
B. Simply documenting the findings as benign is incorrect because hyperpigmentation in these areas (acanthosis nigricans) can be a sign of insulin resistance, which requires further evaluation.
C. Performing a random blood sugar test per order is correct. The symptoms of fatigue, thirst, and frequent urination, along with acanthosis nigricans, strongly suggest diabetes mellitus or insulin resistance. A random blood glucose test can help determine if the client has hyperglycemia.
D. While certain malignancies can be associated with acanthosis nigricans, diabetes is a more common cause. Asking about cancer history is not the priority intervention.

A. Understanding of the referral process. B. Recognition of the client's medical prognosis. C. Drawing inferences about the client. D. Knowledge of anatomy and physiology.

Correct Answer is C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

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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

A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

Correct Answer is C

Explanation

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Correct Answer is C

Explanation

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