While working in the Emergency department a Rapid response nurse is evaluating a patient in acute respiratory failure after a motor vehicle crash. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Soles of the feet
Oral mucosa
Ear lobes
Conjunctivae
The Correct Answer is B
(a) Soles of the feet:
The soles of the feet are not considered the most reliable indicator of central cyanosis because peripheral areas can be affected by various factors, including temperature and circulation. Changes in color here might not accurately reflect central oxygenation status.
(b) Oral mucosa:
The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation status of the central circulatory system. Cyanosis in this area indicates a significant drop in arterial oxygen saturation and is a more direct indicator of hypoxemia compared to peripheral sites.
(c) Ear lobes:
Ear lobes, like the soles of the feet, can be influenced by peripheral circulation and environmental factors. While cyanosis can be observed here, it is not as reliable as central sites like the oral mucosa for assessing systemic oxygenation.
(d) Conjunctivae:
The conjunctivae can show signs of cyanosis, but the oral mucosa is still a more sensitive and reliable indicator for central cyanosis. The oral mucosa provides a clear and consistent site to assess oxygenation in emergency situations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Blockage of the tear ducts causing excessive tearing:
Blockage of tear ducts (dacryostenosis) results in excessive tearing (epiphora) due to inadequate drainage of tears into the nasal cavity. It does not directly contribute to glaucoma, which primarily involves increased intraocular pressure (IOP) and optic nerve damage.
B) Inflammation of the cornea resulting in blurry vision:
Corneal inflammation (keratitis) can cause blurry vision, pain, and sensitivity to light, but it is not the primary pathophysiology of glaucoma. Glaucoma primarily involves damage to the optic nerve due to elevated IOP.
C) Increased intraocular pressure (IOP) leading to optic nerve damage:
Glaucoma is characterized by elevated IOP, which puts pressure on the optic nerve and can lead to progressive damage and vision loss if untreated. This is the primary pathophysiological process in most types of glaucoma.
D) Degeneration of the lens leading to cataracts:
Cataracts involve the clouding of the lens of the eye, leading to visual impairment. While cataracts are a common condition in older adults, they are not directly related to the pathophysiology of glaucoma, which primarily involves elevated IOP and optic nerve damage.
Correct Answer is D
Explanation
A) Electrical cords are placed along the walls: While it is important to ensure that electrical cords are safely managed, cords placed along the walls are less likely to pose a tripping hazard compared to those that are left loose or run across walking paths. This setup, in itself, is generally not a significant safety risk if managed properly.
B) Handrails are present in the bathroom: Handrails in the bathroom are actually a safety feature, not a risk. They provide necessary support for older adults with decreased vision or mobility issues, helping to prevent falls when using the toilet or getting in and out of the bathtub or shower.
C) Uses a microwave for cooking: Using a microwave for cooking is generally considered safe for individuals with decreased vision, as it minimizes the risk of burns and other injuries associated with using a stove or oven. The microwave can be a safer cooking method if the client is familiar with its operation.
D) Scatter rugs are present in the kitchen: Scatter rugs are a significant safety risk, especially for older adults with decreased vision. These rugs can easily cause trips and falls, leading to potentially serious injuries. Removing scatter rugs or securing them with non-slip backing can help mitigate this risk and create a safer home environment.
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