A nurse is assessing a client who has asthma.
Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Conjunctivae.

Soles of the feet.

Oral mucosa.

Ear lobes.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale

The conjunctivae, the mucous membranes that cover the front of the eye and line the inside of the eyelids, can show signs of cyanosis. However, they are not the most reliable indicator of central cyanosis. Central cyanosis is best observed in areas with a rich blood supply and thin skin, where the bluish discoloration due to low oxygen levels in the blood is more apparent.

Choice B rationale

The soles of the feet are not a reliable indicator of central cyanosis. Peripheral cyanosis, which affects the extremities, can occur due to poor circulation or cold temperatures and does not necessarily indicate central cyanosis. Central cyanosis is more accurately assessed in areas with a high concentration of blood vessels and thin skin.

Choice C rationale

The oral mucosa, including the lips and tongue, is the most reliable indicator of central cyanosis. This area has a rich blood supply and thin skin, making it easier to observe the bluish discoloration caused by low oxygen levels in the blood. Central cyanosis is a sign of significant hypoxemia and requires prompt medical attention.

Choice D rationale

The ear lobes are not the most reliable indicator of central cyanosis. While they can show signs of cyanosis, they are not as accurate as the oral mucosa. The ear lobes may be affected by peripheral cyanosis, which can occur due to factors like cold temperatures or poor circulation, rather than central cyanosis.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale

Placing the child on a no-salt-added diet is important for managing fluid retention and hypertension in acute glomerulonephritis, but it is not the immediate priority.

Choice B rationale

Educating the parents about potential complications is essential for long-term management, but it is not the immediate priority in an acute setting.

Choice C rationale

Checking the child’s daily weight is the priority action because it helps monitor fluid balance and detect any signs of fluid retention or worsening condition. Accurate daily weight measurements are crucial for assessing the effectiveness of treatment and making necessary adjustments.

Choice D rationale

Maintaining a saline-lock is important for intravenous access, but it is not the immediate priority compared to monitoring fluid balance through daily weight checks.

A. Developing autonomy. B. Resentment toward the mother. C. Anxiety reaction. D. Regression.

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale

Developing autonomy is a normal developmental milestone for toddlers. However, the behaviors described in the question (sitting quietly, sucking thumb, turning away) are more indicative of regression rather than autonomy.

Choice B rationale

Resentment toward the mother is not a typical developmental reaction for an 18-month-old toddler. The behaviors described are more indicative of regression due to the stress of hospitalization.

Choice C rationale

Anxiety reaction can occur in toddlers who are hospitalized, but the behaviors described (sitting quietly, sucking thumb, turning away) are more indicative of regression.

Choice D rationale

Regression is a common reaction in toddlers who are hospitalized. The behaviors described (sitting quietly, sucking thumb, turning away) are typical signs of regression, where the child reverts to earlier developmental behaviors as a coping mechanism.

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A nurse is assessing a client who has asthma.Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse’s priority?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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A nurse is assessing a client who has asthma.
Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?