The nurse is planning to assess an African American patient's integumentary status. Which finding indicates the presence of cyanosis in this patient?
1. yellow hue in the eyes
2. bluish-tinged nail beds
3. cherry-red lips
4. orange-green cast to the skin
Correct Answer: 2
Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae. A yellowish hue indicates the presence of jaundice. Cherry-red lips are associated with carbon monoxide poisoning. An orange-green cast to the skin is not associated with any specific disorder.
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An 8-year-old child has been diagnosed with a seizure disorder and phenytoin (Dilantin) has been prescribed for him or her. What nursing diagnosis would be appropriate if the child demonstrated adverse effects to the drug?
A) Deficient fluid volume B) Impaired skin integrity related to dermatological effects C) Noncompliance for drug therapy D) Sleep deprivation
A 30-year-old woman has sought care because of her recurrent photophobia, tearing, and eye irritation. During assessment, her care provider asks about any history of cold sores or genital herpes
What is the rationale for the care provider's line of questioning? A) Herpes simplex virus (HSV) conjunctivitis indicated a need for antiviral rather than antibacterial treatment. B) HSV infection of the cornea is a common cause of corneal ulceration and blindness. C) Chronic viral infection of the eyes can result in HSV autoinoculation of the mouth and labia. D) A history of HSV with eye irritation is suggestive of glaucoma.
A patient with diabetes has been diagnosed with osteomyelitis. The nurse notes that the patient's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis?
A) Hematogenous osteomyelitis B) Osteomyelitis with vascular insufficiency C) Contiguous-focus osteomyelitis D) Osteomyelitis with muscular deterioration
A patient asks the nurse, "Can you explain to us how to use the basal body temperature method to detect ovulation and prevent pregnancy?" What response by the nurse is best?
1. "Take your temperature every evening at the same time and keep a record for a period of several weeks. A noticeable drop in temperature indicates that ovulation has occurred." 2. "Take your temperature every day at the same time and keep a record of the findings. A noticeable rise in temperature indicates ovulation." 3. "Take your temperature each day, immediately upon awakening, and keep a record of each finding. A noticeable drop in temperature indicates that ovulation is about to occur." 4. "This is an unscientific and unproven method of determining ovulation, and is not recognized as a means of birth control."