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 ["C","E"]
Explanation
The correct statements that indicate an understanding of discharge teaching for a client recovering from pancreatitis are:
✅ C. "I will eat small, frequent meals." This is recommended to reduce pancreatic stimulation and aid digestion.
✅ E. "I will notify my provider if my urine is dark." Dark urine may indicate worsening jaundice or liver involvement, which requires medical attention.
❌ A. "I will eat fish for dinner at least twice per week." While fish can be part of a healthy diet, the key dietary advice for pancreatitis is to eat low-fat meals. Fatty fish may not be appropriate unless specifically recommended.
❌ B. "I will limit my morning coffee to no more than two cups." Caffeine is not directly contraindicated, but the focus is more on avoiding alcohol and fatty foods. This statement doesn’t reflect core discharge teaching.
❌ D. "I should expect my bowel movements to be pale in color." Pale stools may indicate bile duct obstruction or liver dysfunction and should be reported, not expected.
Correct Answer is C
Explanation
The correct answer is choice C: Document the client’s behavior prior to being placed in seclusion.
Choice A rationale:
Discussing with the client his inappropriate behavior prior to seclusion is important, but it’s not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client’s behavior prior to seclusion.
Choice B rationale:
Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context.
Choice C rationale:
Documenting the client’s behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention.
Choice D rationale:
Assessing the client’s behavior once every hour is important to monitor the client’s condition and response to seclusion. However, this is not the most appropriate action in this context.
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