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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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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. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between

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