The nurse assesses the oral mucosa for pathological color changes. Which does the nurse expect to find in the mouth of a client and why does the nurse expect to find that coloring in the mouth?
1. Ecchymoses because it often is bluish green
2. Cyanosis because it can occur as an ashen tongue
3. Petechiae because they are easily visible in all clients
4. Erythema because the gums should be pink and moist
2
2. The nurse can assess cyanosis, a late sign of hypoxia, in the mouth of a dark-skinned client by examining the tongue for an ashen, gray appearance. In fair-skinned clients, cyanosis is usually observed with pallor or a bluish-gray cast.
1. The nurse expects to find ecchymosis in a fair-skinned client, but it appears as yellowish-green to purple.
3. Petechiae are usually invisible in client's mouths.
4. It is possible to observe erythema in the mouth keeping in mind that the tongue can be beefy red in color.
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