The nursing student is bathing a 73-year-old Native American female client. The student reports to the nurse that the client has what looks like cyanosis on her sacrum
The nurse goes with the student to assess the client but suspects that the cyanosis that the student sees is most likely:
1. Caused from the client laying on her back most of the morning
2. Caused by the bright sunlight in the room
3. Normal hyperpigmentation of mongolian spots
4. Blue dye that has bled off the cheap new gowns that the hospital has purchased
ANS: 3
The nurse should not confuse the normal hyperpigmentation of mongolian spots that are seen on the sacrum of African, Native American, and Asian clients as cyanosis. Observe the client's skin in nonglare daylight. The Gaskin's Nursing Assessment of Skin Color (GNASC) is a useful tool for assessment for identifying changes in skin color that increase the client's risk for pressure ul-cers.
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