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
Fissuring refers to deep cracks or splits in the skin. While it can occur in various skin conditions, it is not a typical manifestation of an allergic reaction to an insect bite.
Choice B rationale
Excoriation refers to a scratch or abrasion on the surface of the skin, often resulting from scratching due to itching. While this can occur secondary to an allergic reaction, it is not a primary characteristic of such reactions.
Choice C rationale
Papules are small, raised, solid bumps on the skin that are typically less than 1 centimeter in diameter. They can be a result of various skin conditions, but they are not specifically associated with allergic reactions to insect bites.
Choice D rationale
Wheals, also known as hives or urticaria, are raised, red or skin-colored welts on the skin that often itch and can appear rapidly in response to an allergen such as an insect bite. They are a characteristic feature of allergic reactions and are caused by the release of histamine.
Correct Answer is B
Explanation
Choice A rationale
Diabetes mellitus can lead to various complications affecting the nails, such as yellowing or thickening due to poor circulation and infections, but it is not typically associated with brittle, concave (spoon-shaped) nails.
Choice B rationale
Iron deficiency anemia is often associated with brittle, spoon-shaped (concave) nails, known as koilonychia. This condition affects the oxygen-carrying capacity of the blood, leading to changes in the nail beds.
Choice C rationale
Coronary heart disease can lead to changes in the nails due to poor circulation, but it is not commonly associated with brittle, concave nails. Other nail changes might include clubbing or cyanosis.
Choice D rationale
Recent candida infection can affect the nails, causing them to become discolored, thickened, or separated from the nail bed, but it does not typically cause the nails to become brittle and concave.