During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding?
a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Ecchymosis
ANS: B
Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.
You might also like to view...
A woman taking magnesium sulfate has respiratory rate of 10 breaths/minute. In addition to discontinuing the medication, the nurse should:
a. vigorously stimulate the woman. b. instruct her to take deep breaths. c. administer calcium gluconate. d. increase her IV fluids.
A client who is being interviewed by the nurse begins pacing and wringing hands, and repeating, "I just need to keep moving." Which statement by the nurse is most appropriate and therapeutic for this client?
A) "Please sit down and relax." B) "Is something bothering you?" C) "The physician will talk with you next." D) "Are you feeling anxious?"
An older person reports eating a small amount of meat for lunch and dinner with a salad and baked potato but only eats dessert on Sunday. Which aspect of a healthy diet is this client describing to the nurse?
a. Habit b. Balance c. Moderation d. Nutrient dense
A researcher attempted to recruit all 150 of the patients seen in the emergency department in a three-month period for diverticulitis, but only 120 consented to participate. What is the refusal rate?
a. 100% b. 80% c. 20% d. 0%