While working in the Emergency department a Rapid response nurse is evaluating a patient in acute respiratory failure after a motor vehicle crash. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

A. Improved wound healing:

While silver sulfadiazine is used to promote wound healing by preventing and treating infections in burn victims, this is not an adverse reaction. This is an intended therapeutic effect of the medication.

B. Allergic reaction in patients with sulfa allergies:

Silver sulfadiazine contains sulfa, and patients who have a sulfa allergy may experience an allergic reaction. This can range from mild skin rashes to severe systemic reactions and is considered a significant adverse reaction.

C. Delayed wound healing:

Silver sulfadiazine is generally used to promote wound healing by preventing bacterial infections. Delayed wound healing is not a common adverse reaction but may occur in some cases due to other underlying factors or if the medication is not effective against certain bacteria.

D. Increased risk of infection:

The primary purpose of silver sulfadiazine is to reduce the risk of infection in burn wounds. An increased risk of infection would indicate a failure of the medication, not an adverse reaction. The correct potential adverse reaction is an allergic response in patients with a known sulfa allergy.

A) Dehydration:

When the skin remains tented and returns to its normal position slowly after being pinched, it indicates decreased skin turgor, which is a clinical sign of dehydration. Dehydration can occur due to fluid loss from sweating during vigorous physical activity like a beach tournament.

B) Hypervolemia:

Hypervolemia refers to excess fluid volume in the body, which would typically manifest with signs such as peripheral edema or jugular vein distention rather than decreased skin turgor.

C) Properly Hydrated:

Properly hydrated individuals would have normal skin turgor, where the skin returns promptly to its normal position after being pinched.

D) Infection:

Skin tenting is not a specific sign of infection. Infection would typically present with localized signs such as redness, warmth, swelling, and possibly systemic signs like fever.