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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Treating upper respiratory infections with over-the-counter medication is not recommended for children with sickle cell anemia. These children are at higher risk for infections and complications, and any signs of infection should be promptly evaluated by a healthcare provider.
Choice B rationale
Ensuring a consistent and daily intake of adequate fluids is crucial for preventing dehydration in children with sickle cell anemia. Dehydration can trigger a sickle cell crisis, leading to severe pain and other complications.
Choice C rationale
Avoiding immunizations is incorrect. Children with sickle cell anemia should receive all recommended vaccinations to prevent infections, which can be more severe in these children.
Choice D rationale
Suggesting that the child participate in sports activities without restriction is not advisable. Children with sickle cell anemia should avoid strenuous activities that can lead to dehydration and trigger a sickle cell crisis. .
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is suitable for assessing pain in infants and young children who cannot verbally communicate their pain. It evaluates five criteria to determine the level of pain.
Choice B rationale
The FACES scale is more appropriate for children aged 3 years and older who can point to the face that best represents their pain level.
Choice C rationale
The OUCHER scale is also designed for older children who can understand and use the photographic or numerical scale to indicate their pain.
Choice D rationale
The PANAD scale is used for assessing pain in patients with advanced dementia and is not suitable for infants.
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