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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Describing the client’s exact words, “body-wracking dry cough” of 6 weeks duration, provides a clear and specific account of the client’s symptoms and concerns.
Choice B rationale
Expressing concern of “lung cancer” symptoms for the last 6 weeks is less specific and does not accurately capture the client’s primary symptom, which is the dry cough.
Choice C rationale
Presenting with a hacking nonproductive cough of 6 weeks duration is a clinical interpretation and does not use the client’s own words, which is important for accurate documentation.
Choice D rationale
An adult male presents with fears that he has “lung cancer” is a subjective interpretation and doeChoice A rationale. Describing the client’s exact words, “body-wracking dry cough” of 6 weeks duration, provides a clear and specific account of the client’s symptoms and concerns.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Measuring skin elasticity around the ankles is not directly related to assessing the cause of cold feet. It is more relevant for assessing hydration status and skin turgor.
Choice B rationale
Assessing the volume of the pedal pulses is crucial to determine if there is adequate blood flow to the feet.
Choice C rationale
Palpating the dorsal surface of the feet for warmth helps assess the temperature and circulation to the feet.
Choice D rationale
Testing for a positive Babinski reflex is not relevant to assessing cold feet. It is used to assess neurological function.
Choice E rationale
Observing the color of the feet and toes helps assess circulation and potential issues such as cyanosis or pallor.