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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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
Explanation
Choice A rationale
Painful symptoms alleviated by warmth are more indicative of conditions such as arthritis or muscle strain rather than venous insufficiency.
Choice B rationale
Cool, pale skin below the knees is more indicative of arterial insufficiency rather than venous insufficiency.
Choice C rationale
Decreased pain when legs are elevated is a common symptom of venous insufficiency. Elevating the legs helps reduce venous pressure and alleviate symptoms such as swelling and aching.
Choice D rationale
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.