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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.

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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A. Number of blood clots expelled with each stool. B. Unique odor noted with gastrointestinal bleeding. C. Color characteristics of each stool. D. Evidence of internal hemorrhoids.

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.

A. Restrict activity to bed rest. B. Monitor urinary output. C. Initiate NPO status. D. Obtain an electrocardiogram.

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

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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Take full exam for free While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

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When evaluating a client’s rectal bleeding, which findings should the nurse document?

Correct Answer is D

Explanation

During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Correct Answer is C

Explanation

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The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

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An older male client reports to the nurse that his feet are cold. Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.

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