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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Exophthalmos:
Exophthalmos, or protruding eyeballs, is typically associated with hyperthyroidism (Graves' disease) rather than hypothyroidism. It results from the accumulation of fluid and swelling behind the eyeballs.
(b) Palpitations:
Palpitations, or rapid heartbeat, are more commonly associated with hyperthyroidism due to the increased metabolic rate and sympathetic nervous system stimulation. In hypothyroidism, bradycardia (slow heart rate) is more likely.
(c) Diaphoresis:
Diaphoresis, or excessive sweating, is not a typical finding in hypothyroidism. It is more commonly associated with conditions that cause autonomic dysfunction or hypermetabolic states.
(d) Weight gain:
Weight gain is a hallmark symptom of hypothyroidism. It occurs due to a slowing down of the metabolic rate, leading to reduced calorie expenditure and potential fluid retention.
Correct Answer is A
Explanation
A) Obesity II:
A Body Mass Index (BMI) of 37 falls within the range of 35 to 39.9, which is classified as Obesity Class II according to the World Health Organization (WHO) BMI categories. This classification indicates a higher risk of obesity-related health conditions and complications.
B) Overweight:
The overweight category corresponds to a BMI range of 25 to 29.9. A BMI of 37 is significantly higher than this range, indicating a more severe level of excess weight and associated health risks.
C) Normal weight:
Normal weight is defined by a BMI range of 18.5 to 24.9. A BMI of 37 is well above this range, indicating that the patient has excess body weight far beyond what is considered normal.
D) Obesity:
While the term "obesity" generally refers to a BMI of 30 or higher, specific classes of obesity (Class I, II, and III) are defined for more precise categorization. A BMI of 37 specifically places the patient in the Obesity II category.
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