The nurse is concerned that an African American client is experiencing cyanosis. Which of the following signs of cyanosis would the nurse look for in this client?
a. The presence of excess interstitial fluid with a decreased elasticity or fullness of the skin
b. A bluish tinge in the skin, tongue, and mucous membranes that does not blanch when pressure is applied
c. A redness and a variety of rashes over the entire body
d. An absence of underlying red tones in the skin most readily seen in the buccal mucosa
B
Cyanosis is a bluish tinge most evident in the skin, tongue, and mucous membranes. Bruised areas normally blanch when pressure is applied. Pallor occurs when there is too little circulating blood or hemoglobin and is characterized by the absence of underlying red tones. Erythema is a redness associated with a variety of rashes, and edema is the presence of excess interstitial fluid. It is important to note that pallor, cyanosis, and erythema may appear differently in clients with brown or black skin, and the nurse must take care not to overlook abnormal findings.
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