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 A
Explanation
Choice A rationale
Pupils equal, round, and reactive to light (PERRL) accurately summarizes the findings of the pupillary assessment. It indicates that both pupils are equal in size, round in shape, and react briskly to light, which is a normal finding.
Choice B rationale
Documenting “neurological status intact” is too vague and does not specifically describe the pupillary assessment findings.
Choice C rationale
Pupils equal, round, reactive to light, and accommodation (PERLA) includes an additional assessment of accommodation, which was not mentioned in the scenario.
Choice D rationale
The Glasgow Coma Scale (GCS) of 15 is a general assessment of consciousness and does not specifically describe the pupillary findings.
Correct Answer is A
Explanation
Choice A rationale
Epigastric region is the correct answer. The epigastric region is the area of the abdomen located between the lower part of the ribcage and the navel (umbilicus). Pain localized in the middle section of the abdomen below the xiphoid process corresponds to the epigastric region.
Choice B rationale
The umbilical region is located around the navel (umbilicus) in the center of the abdomen. Pain in the umbilical region may be associated with conditions affecting the small intestine or structures around the navel, such as umbilical hernias.
Choice C rationale
The hypogastric region is located in the lower part of the abdomen, below the umbilical region. Pain in the hypogastric region typically corresponds to the lower abdomen, around the pubic bone.
Choice D rationale
The hypochondriac regions are located on each side of the upper abdomen, beneath the ribs. Pain in the hypochondriac region may be associated with conditions affecting the liver, gallbladder, or spleen.