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 C
Explanation
Choice A rationale
Documenting the presence of borborygmi is appropriate, but it does not address the need for a thorough assessment of all quadrants. Borborygmi are loud, high-pitched, almost continuous gurgling sounds that indicate hyperactive bowel sounds.
Choice B rationale
Auscultating the remaining quadrants is necessary to complete the assessment and ensure that the findings are consistent throughout the abdomen. This step helps to identify any variations in bowel sounds that may indicate different underlying conditions.
Choice C rationale
Elevating the head of the client’s bed immediately is not indicated in this situation. The primary focus should be on completing the assessment of bowel sounds in all quadrants.
Choice D rationale
Using the bell of the stethoscope to auscultate again is not necessary, as the diaphragm is the appropriate part of the stethoscope to use for assessing bowel sounds. The diaphragm is better suited for picking up high-pitched sounds like borborygmi.
Correct Answer is ["C","D"]
Explanation
Choice A rationale
The right side of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Choice B rationale
The center of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Choice C rationale
The apex of the heart is where S1 is loudest. S1 is caused by the closure of the mitral and tricuspid valves and is best heard at the apex.
Choice D rationale
The base of the heart is where S2 is loudest. S2 is caused by the closure of the aortic and pulmonic valves and is best heard at the base.
Choice E rationale
The left side of the heart is not specifically associated with the loudest heart sounds for S1 or S213.