The nurse assesses the oral mucosa for pathological color changes. Which finding does the nurse expect to see in the patient's mouth, and why does the nurse expect to find it?
a. Ecchymosis, because it often is bluish green
b. Cyanosis, because it can occur as an ashen tongue
c. Petechiae, because they are easily visible in all patients
d. Erythema, because the gums should be pink and moist
B
The nurse can assess cyanosis, a late sign of hypoxia, in the mouth of a dark-skinned patient by examining the tongue for an ashen gray appearance. In fair-skinned patients, cyanosis is usually observed with pallor or a bluish-gray cast. The nurse expects to find ecchymosis in a fair-skinned patient, but it appears as yellowish green to purple. Petechiae are usually invisible in patients' mouths. 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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