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 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 B
Explanation
A. Early ventricular repolarization is represented by the T wave, not the P wave.
B. The P wave represents atrial depolarization, which is the electrical activity that triggers the contraction of the atria.
C. Slow repolarization of ventricular Purkinje fibers is represented by the T wave, not the P wave.
D. Ventricular depolarization is represented by the QRS complex, not the P wave.