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. Муоріа B. Normal eye movement C. Ptosis will be evident and no pupillary constriction. D. The eye cannot look to the outside side.

Correct Answer is C

Explanation

(a) Mydriasis:

While mydriasis (dilated pupil) can be associated with cranial nerve III damage, it does not fully describe the range of symptoms expected with oculomotor paralysis. Cranial nerve III controls more functions than pupil dilation, such as eyelid elevation and certain eye movements.

(b) Normal eye movement:

Cranial nerve III paralysis would result in abnormal eye movement due to the loss of control over muscles responsible for moving the eye. Expecting normal eye movement would be incorrect since the paralysis affects the eye's ability to move properly.

Cranial nerve III (oculomotor nerve) paralysis leads to ptosis (drooping eyelid) because it innervates the levator palpebrae superioris muscle. It also affects the pupillary constrictor muscles, resulting in a dilated pupil (lack of pupillary constriction), making this the most comprehensive and accurate answer.

(d) The eye cannot look to the outside side:

Inability to look to the outside (lateral movement) is typically associated with cranial nerve VI (abducens nerve) paralysis, which controls the lateral rectus muscle. Cranial nerve III primarily affects vertical and medial movements, so this is not the expected finding.

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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

The nurse read the patient's health history cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

Correct Answer is C

Explanation

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