Which finding should the nurse expect when assessing a client who is cyanotic?
Bradypnea
Pale reddish color in the skin
Somnolence
Mottled blue color in skin
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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Correct Answer is A
Explanation
A. Facial drooping is a common symptom following a stroke, particularly if it affects areas of the brain responsible for facial movement.
B. Frequent diarrhea is not typically associated with stroke and may be related to other factors.
C. A steady gait is unlikely following a stroke, especially if the stroke has affected motor control or balance.
D. Vocal clarity can be affected after a stroke, but facial drooping is a more immediate and recognizable alteration in neurologic function.
Correct Answer is A
Explanation
A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.
B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.
C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.
D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.