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

A.

Cornea are jaundiced.

B.

Face is flushed and diaphoretic.

C.

Oral mucosa is cyanotic.

D.

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Paresthesia refers to abnormal sensations such as tingling or numbness, which is not indicated by the client’s ability to sense two points at specific distances.

Choice B rationale

A marginal decline in sensory function would be indicated by a significant increase in the distance required to sense two points, which is not the case here.

Choice C rationale

A rebound reaction to the needle points is not a recognized interpretation of the two-point discrimination test.

Choice D rationale

The client’s ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination.

Correct Answer is D

Explanation

Choice A rationale

Giving the client 8 ounces (236.5 mL) of water to drink may help in obtaining a urine sample, but it does not address the immediate concern of potential bladder distention.

Choice B rationale

Sending the sample for laboratory evaluation is not appropriate when the sample is insufficient. The nurse should first address the underlying issue of why the client could not provide an adequate sample.

Choice C rationale

Instructing the client to attempt to urinate again may not be effective if the client is experiencing bladder distention or another underlying issue preventing urination.

Choice D rationale

Evaluating the client for bladder distention is the most appropriate action. Bladder distention can cause lower abdominal discomfort and difficulty urinating. Assessing for distention can help determine if the client needs further intervention, such as catheterization.

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