The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

Blue tinge in the nail beds.

Ashen grey tone to lips.

Ashy yellow appearance of skin.

Reddish purple colored palms.

Answer and Explanation

The Correct Answer is A

A. Blue tinge in the nail beds: This finding is indicative of cyanosis. When oxygen levels in the blood are low, the skin and mucous membranes may appear bluish due to inadequate oxygenation. The nail beds are a common area to observe this bluish discoloration.

B. Ashen grey tone to lips: While this can be concerning, it is not a classic sign of cyanosis. Ashen grey lips may be associated with other conditions, such as shock or poor perfusion, but they do not specifically indicate cyanosis.

C. Ashy yellow appearance of skin: This finding is not related to cyanosis. An ashy yellow appearance may be seen in conditions like liver disease or jaundice, but it does not reflect oxygenation status.

D. Reddish purple colored palms: Again, this is not a sign of cyanosis. Reddish or purple palms may be seen in various conditions, but they do not specifically point to inadequate oxygen levels.

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Correct Answer is A

Explanation

A. "What were you doing when you first noticed the problem?"

This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

B. "Have you taken any medications to relieve the pain?"

While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

C. "Do you remember ever having this type of pain in the past?"

This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

D. "Does changing your position make the pain worse?"

This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

A. Assess subconjunctival color for pallor B. Review serum creatinine results. C. No additional assessment needed. D. Obtain every 2-hour blood pressure readings.

Correct Answer is C

Explanation

A. Assess subconjunctival colour for pallor. Subconjunctival colour assessment is not directly related to hyperpigmented freckles and is not typically indicated in this scenario.

B. Review serum creatinine results. Serum creatinine levels are not directly related to hyperpigmented freckles unless there are specific concerns about kidney function, which are not mentioned in the scenario.

C. No additional assessment needed. Hyperpigmented freckles are common benign skin findings in older adults and do not typically require further assessment unless there are other concerning symptoms or lesions present.

D. Obtain every 2-hour blood pressure readings. Blood pressure monitoring at such frequent intervals is not indicated based solely on the presence of hyperpigmented freckles.

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The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

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Naxlex Comprehensive Predictor Exams

The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

Correct Answer is A

Explanation

While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

Correct Answer is C

Explanation

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