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

Answer and Explanation

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.

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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Correct Answer is A

Explanation

A) "Let's discuss your risk factors for heart disease.":

A waist circumference of 43 inches (109 cm) in a male is considered elevated and indicates central obesity, which is a significant risk factor for cardiovascular diseases, including heart disease, hypertension, and type 2 diabetes. Addressing this finding by discussing risk factors for heart disease is appropriate and necessary for preventive healthcare.

B) "We should review the amount of protein in your diet.":

While diet is important, protein intake is not directly related to waist circumference. The primary concern with a large waist circumference is the associated risk of metabolic and cardiovascular conditions, rather than specific macronutrient consumption.

C) "Waist circumference can vary over the course of the day.":

Though there can be minor variations in waist circumference throughout the day due to factors like fluid retention or meals, a measurement of 43 inches is significantly above the threshold indicating central obesity. This warrants a discussion about health risks rather than focusing on daily fluctuations.

D) "You probably have a vitamin deficiency.":

Vitamin deficiencies are not directly indicated by waist circumference measurements. This statement is not appropriate given the finding, as the primary concern with a large waist circumference is its association with increased risk of chronic diseases rather than nutrient deficiencies.

A. Fish B. Leafy green vegetables C. Corn oil D. Dietary supplements

Correct Answer is A

Explanation

A) Fish: Fish, especially fatty fish like salmon, mackerel, sardines, and trout, are rich sources of omega-3 fatty acids. Omega-3 fatty acids are essential for heart health, reducing inflammation, and supporting brain function. Including fish in the diet is highly recommended for obtaining these beneficial fats naturally.

B) Leafy green vegetables: While leafy green vegetables provide many essential nutrients, they are not significant sources of omega-3 fatty acids. They are more commonly known for their vitamins, minerals, and fiber content, which are important for overall health but do not provide the omega-3s that fish does.

C) Corn oil: Corn oil is high in omega-6 fatty acids rather than omega-3 fatty acids. While omega-6 fatty acids are also necessary for health, they should be balanced with omega-3s to maintain optimal health. Corn oil does not contribute significantly to omega-3 intake.

D) Dietary supplements: While omega-3 supplements can be a good alternative for those who do not consume enough fish, obtaining nutrients from whole foods is generally preferred for additional health benefits, such as protein and other nutrients found in fish. Supplements should be considered when dietary intake is insufficient.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding?

Correct Answer is A

Explanation

A nurse is instructing a group of clients regarding nutrition. Which of the following is a good source of omega-3 fatty acids that the nurse should include in the teaching?

Correct Answer is A

Explanation

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?

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