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While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

A.

Cornea are jaundiced.

B.

Face is flushed and diaphoretic.

C.

Oral mucosa is cyanotic.

D.

Eyelids are matted and crusted.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, the nurse should continue with the remainder of the client’s physical assessment.

Choice B rationale

Reporting the client’s lung sounds to the healthcare provider is unnecessary because vesicular breath sounds are normal and do not indicate any abnormality.

Choice C rationale

Asking the client to cough and then auscultate at the site again is not required since vesicular breath sounds are normal and do not indicate any need for further immediate assessment.

Choice D rationale

Measuring the client’s oxygen saturation with a pulse oximeter is not necessary in this context because the vesicular breath sounds indicate normal lung function.

Correct Answer is B

Explanation

Choice A rationale

Sorting a collection of socks may assess cognitive function and fine motor skills, but it does not directly evaluate the ability to perform activities of daily living (ADL) such as bathing, dressing, or feeding.

Choice B rationale

Opening a bar soap package is a practical task that requires fine motor skills and dexterity, which are essential for performing activities of daily living (ADL) such as bathing and grooming.

Choice C rationale

Telephoning a family member assesses communication skills and cognitive function but does not directly evaluate the ability to perform activities of daily living (ADL).

Choice D rationale

Reading a short paragraph assesses cognitive function and literacy skills but does not directly evaluate the ability to perform activities of daily living (ADL).

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