A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?
Pallor
Jaundice
Cyanosis
Erythema
The Correct Answer is C
A. Pallor:
Pallor refers to an unusually pale or white skin color. It is often associated with reduced blood flow, anemia, or shock. Pallor is characterized by a lack of the normal rosy color of the skin.
B. Jaundice:
Jaundice is a yellowing of the skin and mucous membranes due to an excess of bilirubin in the blood. It can be associated with liver dysfunction or other conditions affecting the normal breakdown and elimination of bilirubin.
C. Cyanosis:
Cyanosis is a bluish-gray discoloration of the skin and mucous membranes caused by a decrease in oxygen levels in the blood. It can result from various conditions affecting oxygenation, such as respiratory or circulatory problems. In the context of a broken leg, cyanosis on the affected leg could suggest compromised blood flow or oxygenation.
D. Erythema:
Erythema refers to redness of the skin, often due to increased blood flow to the area. It can be a normal response to irritation, injury, or inflammation. Unlike bluish-gray discoloration seen in cyanosis, erythema is characterized by a red appearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Carotid
The nurse should avoid assessing the carotid pulses bilaterally at the same time. The carotid arteries are major blood vessels supplying the head and neck with oxygenated blood. Simultaneously assessing both carotid pulses could potentially compromise blood flow to the brain, leading to a decrease in cerebral perfusion. This is particularly important in individuals with a history of cerebrovascular disease or other conditions affecting blood flow to the brain.
B. Brachial:
Assessing the brachial pulses bilaterally at the same time is generally acceptable. The brachial pulses are located in the upper arms.
C. Popliteal:
Assessing the popliteal pulses bilaterally at the same time is generally acceptable. The popliteal pulses are located behind the knee.
D. Femoral:
Assessing the femoral pulses bilaterally at the same time is generally acceptable. The femoral pulses are located in the groin area.
Correct Answer is C
Explanation
A. Performs auscultation between meals:
Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.
B. Clamps the Naso Gastric tube during auscultation
Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.
C. Palpates the abdomen prior to performing auscultation:
Palpating the abdomen before auscultation may interfere with normal bowel sounds
D. Auscultates bowel sounds for 3 to 5 min:
Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.
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