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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.

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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A. Increase intake of red meat. B. Splint the affected joint. C. Encourage fluid intake. D. Measure urine output.

Correct Answer is C

Explanation

Choice A rationale

Increasing the intake of red meat is not advisable for clients with elevated serum uric acid levels, as red meat is high in purines, which can exacerbate gout symptoms.

Choice B rationale

Splinting the affected joint may provide temporary relief from pain, but it does not address the underlying issue of elevated serum uric acid levels.

Choice C rationale

Encouraging fluid intake is essential for clients with elevated serum uric acid levels, as it helps to dilute the urine and promote the excretion of uric acid, reducing the risk of gout attacks.

Choice D rationale

Measuring urine output is important for monitoring kidney function, but it does not directly address the management of elevated serum uric acid levels.

A. Packs of cigarettes smoked per day. B. Number of attempts to quit smoking. C. Client’s current age. D. Age when the client started smoking. E. Number of years the client smoked.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale

Packs of cigarettes smoked per day is essential information for calculating smoking pack years.

Choice B rationale

The number of attempts to quit smoking is not required for calculating smoking pack years.

Choice C rationale

The client’s current age is not required for calculating smoking pack years.

Choice D rationale

The age when the client started smoking is necessary to determine the total number of years smoked.

Choice E rationale

The number of years the client smoked is essential for calculating smoking pack years.

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

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Correct Answer is C

Explanation

Correct Answer is ["A","D","E"]

Explanation

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Take full exam for free While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

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The nurse examines a client’s right great toe.The joint is red, edematous, and very painful with limited range of motion. The client’s serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Correct Answer is C

Explanation

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

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The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

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While auscultating a client’s breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years.The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

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