While observing a client’s face, which assessment finding requires immediate intervention by the nurse?
Cornea are jaundiced.
Face is flushed and diaphoretic.
Oral mucosa is cyanotic.
Eyelids are matted and crusted.
The Correct Answer is C
Choice A rationale
Jaundiced corneas indicate liver dysfunction or other serious conditions that require medical attention, but they do not require immediate intervention compared to cyanosis.
Choice B rationale
A flushed and diaphoretic face can indicate fever, heat exhaustion, or other conditions, but it is not as immediately life-threatening as cyanosis.
Choice C rationale
Cyanotic oral mucosa indicates a lack of oxygen in the blood, which is a medical emergency requiring immediate intervention.
Choice D rationale
Matted and crusted eyelids can indicate an eye infection or other conditions, but they do not require immediate intervention compared to cyanosis.
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Correct Answer is B
Explanation
Choice A rationale
A 75-year-old with a pneumothorax and a chest tube may have a displaced PMI due to the pneumothorax, but it is not necessarily difficult to locate. The chest tube may also cause some displacement, but it is not the primary factor affecting PMI location.
Choice B rationale
A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg) is likely to have difficulty locating the PMI due to the increased adipose tissue. Obesity can make it challenging to palpate the PMI as the excess tissue can obscure the heart’s apex.
Choice C rationale
A 2-year-old who is demonstrating diaphragmatic breathing may have a PMI that is slightly higher and more medial than in adults, but it is generally not difficult to locate.
Choice D rationale
A 45-year-old long-distance runner with a body mass index (BMI) of 18 kg/m² is likely to have a more prominent PMI due to a leaner body composition and a potentially enlarged heart from athletic conditioning.
Correct Answer is B
Explanation
Choice A rationale
A translucent, pearly gray, and mobile tympanic membrane is a normal finding and does not align with the symptoms of itching, pain, and discharge.
Choice B rationale
A red, edematous ear canal with no visualization of the tympanic membrane is indicative of otitis externa, commonly known as “swimmer’s ear.”. This condition is characterized by inflammation and infection of the external ear canal, often following swimming.
Choice C rationale
A thickened and bulging tympanic membrane is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum.
Choice D rationale
A retracted and non-mobile tympanic membrane is typically associated with eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described.