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 B
Explanation
Choice A rationale
Asking the client to describe any other related symptoms is important for a comprehensive assessment but does not objectively confirm the presence of fever.
Choice B rationale
Placing the dorsum of the hand on the client’s forehead is a quick and practical method to assess for fever. It provides an initial subjective assessment of the client’s temperature before taking an accurate measurement with a thermometer.
Choice C rationale
Using both hands to hold and palpate the client’s hands may help assess for other symptoms such as clamminess or coldness but does not objectively confirm the presence of fever.
Choice D rationale
Lightly pinching a fold of skin over the client’s sternum assesses skin turgor and hydration status but does not objectively confirm the presence of fever.
Correct Answer is B
Explanation
Choice A rationale
An audible thud without pain is a normal finding when percussing the costovertebral angle (CVA) in a healthy individual. This indicates that there is no inflammation or infection in the kidneys or surrounding tissues.
Choice B rationale
Sharp, severe pain upon percussion of the CVA is a classic sign of pyelonephritis. This pain is due to the inflammation and infection of the kidney, which causes tenderness in the area.
Choice C rationale
Rebound tenderness is typically associated with peritoneal irritation, such as in cases of appendicitis or peritonitis. It is not a common finding in pyelonephritis.
Choice D rationale
Rigidity and firmness are more indicative of muscle spasms or guarding, which can occur in conditions like peritonitis or severe abdominal pain, but not specifically in pyelonephritis.