The nurse observes ashen-colored lips and tongue on the client with dark skin. Which does the nurse want to rule out by using a focused assessment?
1. Jaundice
2. Cyanosis
3. Erythema
4. Hypoxemia
4
4. Pallor in a dark-skinned person manifests as ashen-colored lips, tongue, and muc-ous membranes; pallor is a potential result of hypoxemia and vasoconstriction from a cold environment. The nurse continues with a focused assessment of client oxygena-tion, including oxygen saturation, respiratory rate, breath sounds, and skin tempera-ture to rule out hypoxemia.
1. The nurse assesses a client with dark skin for jaundice by examining the sclerae, hard palate, palms, and soles.
2. Ashen-colored mucous membranes are a description for cyanosis.
3. Redness, or erythema, is difficult to assess in a client with dark skin, so the nurse palpates for warmth with fever and inflammation.
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The nurse knows that the two factors that often differentiate major depression from dysthymia depression are:
A. Amounts of mania and sadness. B. Presence or absence of anger and guilt. C. Severity and duration of symptoms. D. Patient's gender and age.
A patient is scheduled for the surgical removal of dead tissue associated with the condition gas gangrene. A nurse identifies this process as ____________________
Fill in the blank with correct word.
A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find?
a. Blood urea nitrogen (BUN) of 52 mg/dL b. Creatinine of 2.3 mg/dL c. BUN of 10 mg/dL d. BUN/creatinine ratio of 8:1
The nurse tells a high school senior who is newly diagnosed with herpes that the rise in the number of sexually transmitted infections (STIs) can be attributed to: (Select all that apply.)
a. an increase in the number of sexually ac-tive teenagers. b. an increase in the opportunity to have multiple partners. c. knowledge deficit about signs and symp-toms of STIs. d. teenagers being reluctant to report diseas-es. e. young people's inability to acquire confi-dential health care.