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 D
Explanation
Choice A rationale
Observing balance while the client stands assesses overall balance but does not specifically evaluate hip dysfunction.
Choice B rationale
Inspecting gluteal folds for symmetry can provide information about hip alignment but does not directly assess hip function.
Choice C rationale
Flexing the hip and knee while standing assesses range of motion but may not fully evaluate hip dysfunction.
Choice D rationale
Abducting each hip while the client is supine is a specific test to assess hip function and can help identify hip dysfunction.
Correct Answer is C
Explanation
Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.