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
While the number of blood clots expelled with each stool may be relevant in assessing the severity of bleeding, it does not provide as much information about the potential underlying causes of bleeding as documenting the color characteristics of the stool does.
Choice B rationale
Documenting evidence of internal hemorrhoids is important in assessing rectal bleeding, but it is not as fundamental as documenting the color characteristics of the stool. Internal hemorrhoids can be one potential cause of rectal bleeding, but other more serious conditions may also cause bleeding.
Choice C rationale
While gastrointestinal bleeding may have a distinct odor, documenting this alone does not provide as much diagnostic information as describing the color characteristics of the stool. Documenting odor may be important in some cases, but it is not as critical as documenting the color of the stool.
Choice D rationale
When evaluating rectal bleeding, documenting the color characteristics of each stool is crucial. Different colors of stool can indicate various underlying causes of bleeding. Bright red blood typically suggests lower gastrointestinal bleeding, while darker, tarry stools (melena) may indicate bleeding higher in the gastrointestinal tract.
Correct Answer is B
Explanation
Choice A rationale
A 75-year-old with a pneumothorax and a chest tube may have a displaced PMI due to the pneumothorax, but it is not necessarily difficult to locate. The chest tube may also cause some displacement, but it is not the primary factor affecting PMI location.
Choice B rationale
A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg) is likely to have difficulty locating the PMI due to the increased adipose tissue. Obesity can make it challenging to palpate the PMI as the excess tissue can obscure the heart’s apex.
Choice C rationale
A 2-year-old who is demonstrating diaphragmatic breathing may have a PMI that is slightly higher and more medial than in adults, but it is generally not difficult to locate.
Choice D rationale
A 45-year-old long-distance runner with a body mass index (BMI) of 18 kg/m² is likely to have a more prominent PMI due to a leaner body composition and a potentially enlarged heart from athletic conditioning.