A dark-skinned client was admitted in respiratory distress. When ...

[Melani1276]

A dark-skinned client was admitted in respiratory distress. When planning to assess for cyanosis, the nurse recognizes that:
 
  1. It is not possible to assess color changes in clients with dark skin.
  2. Cyanosis can be seen on the lips and mucous membranes of clients with dark skin.
  3. Cyanosis in clients with dark skin is assessed through the sclera.
  4. Cyanosis will blanch with direct pressure to the soles of the feet in dark-skinned clients.

Question 2

While inspecting the pressure ulcer of a 90-year-old client, the nurse observes new tissue growth around the area, which is pinkish-red in color. The nurse should document the presence of:
 
  1. epithelialization.
  2. slough.
  3. granulation.
  4. eschar.

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Answer to Question 1

Answer: 2

1. A bluish discoloration of the mucous membranes indicates cyanosis in clients with dark skin.
2. A bluish discoloration of the mucous membranes indicates cyanosis in clients with dark skin.
3. A bluish discoloration of the mucous membranes indicates cyanosis in clients with dark skin.
4. A bluish discoloration of the mucous membranes indicates cyanosis in clients with dark skin.

Answer to Question 2

Answer: 3

1. Epithelialization is a process of new cell growth.
2. Slough is the semi-liquid white and yellow tissue seen in a wound bed.
3. The pinkish-red tissue is new tissue growth in the wound bed, called granulation tissue.
4. Eschar appears as black or brown, dried, hardened necrotic tissue.

[Melani1276]

TYSM

[adf223]

Gracias!