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 C
Explanation
Choice A rationale
Recent over-the-counter infection cures are less relevant compared to the physical characteristics of the lymph nodes when assessing for potential malignancy.
Choice B rationale
The number of indoor cats at home is not directly related to the assessment of enlarged lymph nodes in the axilla.
Choice C rationale
Nontender firm lymph nodes are a significant finding that may indicate a more serious underlying condition, such as malignancy. This information is crucial for the healthcare provider to determine the next steps in diagnosis and treatment.
Choice D rationale
The amount of daily caffeine consumption is not relevant to the assessment of enlarged lymph nodes in the axilla
Correct Answer is C
Explanation
Choice A rationale
White blood cell count (WBC) is typically monitored to assess for signs of infection or inflammation. While it’s important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection.
Choice B rationale
Blood urea nitrogen (BUN) levels can be elevated in cases of gastrointestinal bleeding due to the breakdown of blood proteins in the gut. However, BUN is not the primary test to monitor in response to melena.
Choice C rationale
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information about the client’s red blood cell volume and can indicate the extent of blood loss.
Choice D rationale
Glucose levels are not directly related to melena. Monitoring glucose levels is essential for managing diabetes and other metabolic conditions but is not relevant to assessing the impact of gastrointestinal bleeding.