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 ["C","D","E"]
Explanation
A. Numbness in the right arm is not a risk factor for skin cancer; it is more related to neurological issues or circulation problems.
B. While working in a beauty parlor may involve exposure to certain chemicals, it is not a significant risk factor for skin cancer compared to other options.
C. A client with a fair skin complexion and blue eyes has a higher risk for skin cancer due to lower melanin levels, making them more susceptible to UV damage.
D. Smoking is primarily associated with lung cancer; however, it can also contribute to skin damage and increased risk for skin cancer, particularly squamous cell carcinoma.
E. A roofer who spends a lot of time outdoors and experiences blistering sunburns is at significant risk for skin cancer due to excessive UV exposure and history of severe sunburns.
Correct Answer is C
Explanation
A. The patient's chart may provide historical information but does not reflect the current pain intensity the client is experiencing.
B. Visual observation for nonverbal signs of pain can be useful, especially for nonverbal patients, but self-reporting is the most accurate measure of pain intensity.
C. The client's self-report of pain severity is the gold standard for assessing pain intensity, as it reflects the individual’s personal experience of pain.
D. While the nature and invasiveness of the surgical procedure can provide context for expected pain levels, they do not replace the importance of the client's self-report in managing pain effectively.