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

A.

Cornea are jaundiced.

B.

Face is flushed and diaphoretic.

C.

Oral mucosa is cyanotic.

D.

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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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.

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