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Which finding should the nurse expect when assessing a client who is cyanotic?

A.

Bradypnea

B.

Pale reddish color in the skin

C.

Somnolence

D.

Mottled blue color in skin

Answer and Explanation

The Correct Answer is D

A. Bradypnea (slow breathing) may occur in various conditions but is not a defining characteristic of cyanosis.  

 

B. A pale reddish color in the skin is not consistent with cyanosis, which indicates a lack of oxygen in the blood.  

 

C. Somnolence (drowsiness) may be present in some patients, but it is not a specific finding related to cyanosis.  

 

D. Mottled blue color in the skin is a classic sign of cyanosis, indicating inadequate oxygenation of the blood, especially in the extremities or areas with poor circulation.


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View Related questions

Correct Answer is D

Explanation

A. Checking pupillary response to light assesses cranial nerve II (optic nerve).

B. Observing for facial symmetry primarily assesses cranial nerves VII (facial nerve) and possibly V (trigeminal nerve).

C. Testing for sense of smell assesses cranial nerve I (olfactory nerve).

D. Eliciting the gag reflex assesses cranial nerve IX (glossopharyngeal nerve) and also cranial nerve X (vagus nerve), making it the correct action to assess cranial nerve IX.

Correct Answer is D

Explanation

A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.

B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.

C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.

D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.

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