During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

Nail Beds

Sclera

Oral Mucosa

Palms

Answer and Explanation

The Correct Answer is C

A. Nail Beds:

While peripheral cyanosis can cause bluish discoloration of the nail beds, central cyanosis is more indicative of systemic hypoxemia and is best assessed in areas with rich blood supply, such as the oral mucosa.

B. Sclera:

The sclera is more commonly used to assess for jaundice (yellowing) rather than cyanosis. Cyanosis is not typically visible in the sclera.

C. Oral Mucosa:

Central cyanosis is most accurately assessed in areas with high vascularization, such as the oral mucosa. This area provides a clear indication of oxygenation status and can reveal hypoxemia more reliably than peripheral sites.

D. Palms:

Similar to the nail beds, the palms can show signs of peripheral cyanosis but are not the primary site for assessing central cyanosis. The oral mucosa remains the best site for this assessment.

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Correct Answer is C

Explanation

The Body Mass Index (BMI) is calculated using the formula:

BMI = weight(kg) / height(m)2

First, we need to convert the height from feet and inches to meters.

There are approximately 0.3048 meters in a foot and 0.0254 meters in an inch.

So, 5 feet 5 inches is approximately 1.65 meters.

Substituting the given values into the formula:

BMI = 60 / (1.65)2

This gives us a BMI of approximately 22 when rounded to the nearest whole number.

Therefore, the correct answer is 22 BMI.

A. Encourage the client to look at the balance beam B. Have the client wear the same clothing every day. C. Weigh the client at the same time in the morning D. Use the same scale to weigh the client. E. Discuss the client's weight with her after each measurement.

Correct Answer is ["B","C","D"]

Explanation

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a 60kg adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client? Round to the whole number.

Correct Answer is C

Explanation

A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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