A nurse is performing a skin assessment on a client who has dark skin.
Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?
Area of trauma.
Sacrum.
Shoulders.
Palms of the hands.
The Correct Answer is D
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.
These areas are less affected by melanin, the pigment that gives skin its color.
Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
The findings that require immediate follow-up are:.
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- Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. “My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me.”.
- Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports not wanting to eat anymore. Client’s child reports their parent has lost about 8 lb in the past month.
- Client says. "Why don’t you just leave me? I am of no use.”.
These findings suggest that the client may have cognitive impairment, depression, and/or malnutrition, which can affect their health and quality of life. The nurse should perform a comprehensive assessment of the client’s cognitive, behavioral, and functional status, review their medications and possible side effects, provide education and support for healthy aging, and collaborate with interdisciplinary teams and community resources. The nurse should also evaluate the client’s home environment and lifestyle, and consider nonpharmacological approaches to manage behavioral problems. The nurse should also monitor the client’s vital signs and weight regularly.
Correct Answer is A
Explanation
The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states. Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.
Choice B is wrong because antitoxin is not used to treat Lyme disease.
Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.
Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.
Choice D is wrong because skin necrosis is not a common complication of Lyme disease.
Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.
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