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","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.
Correct Answer is B
Explanation
ChoiceArationale
Abenignvariationwouldnottypicallypresentwithapatternofdullnessextendingfromthe 5th left intercostal space to the 2nd left intercostal space at the sternal border. This pattern suggests an abnormality rather than a benign variation.
ChoiceBrationale
Cardiacenlargementisindicatedbyanareaofdullnessextendingfromthe5thleftintercostal space to the 2nd left intercostal space at the sternal border. This finding suggests an enlarged heart, which can be due to conditions such as cardiomegaly or left ventricular hypertrophy.
ChoiceCrationale
Cardiacatrophyrefersto adecreaseinthesizeormassoftheheartmuscle,resultingina smaller than normal heart. The described findings indicate dullness extending upward, suggesting an enlargement rather than atrophy of the heart.
ChoiceDrationale
Anexpectedfindingwouldnottypicallypresentwiththedescribedpatternofdullness.The normal area of cardiac dullness is more limited and does not extend as described.