The nurse observes that a client has cyanosis. On which part of ...

[SAVANNAHHOOPER23]

The nurse observes that a client has cyanosis. On which part of the physical assessment should the nurse focus with this client?
 
  1. Activity
  2. Heart sounds
  3. Oxygen levels
  4. Lung sounds

Question 2

The nurse notes that a client's skin turgor is nonelastic and the skin folds remain elevated. What should the nurse suspect is occurring with this client?
 
  1. Dehydration
  2. Lesions
  3. Edema
  4. Hypothermia

[akudia]

Answer to Question 1

Answer: 3

1. Activity status will not explain the presence of cyanosis.
2. Heart sounds will not help explain the presence of cyanosis.
3. Cyanosis is a result of decreased levels of oxygen in the blood.
4. Lung sounds may or may not help determine the cause for cyanosis.

Answer to Question 2

Answer: 1

1. A lack of water, as seen with dehydration, decreases the fullness and elasticity of the skin.
2. Lesions usually do not affect skin turgor.
3. Excess fluid would cause edema.
4. Body temperature usually does not affect skin turgor.