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 A
Explanation
Choice A rationale
Intranasal edema and swelling of turbinates are classic signs of allergic rhinitis. Allergic rhinitis is an inflammatory response to allergens, leading to swelling and congestion in the nasal passages. The turbinates, which are structures inside the nose that help filter and humidify the air, become swollen due to the inflammatory response, causing symptoms such as nasal congestion, runny nose, and sneezing.
Choice B rationale
Purulent secretions from the eyes and nares are more indicative of an infection, such as bacterial sinusitis or conjunctivitis, rather than allergic rhinitis. Allergic rhinitis typically involves clear, watery secretions rather than purulent (pus-like) discharge.
Choice C rationale
Snoring and bilateral, pale gray nodules are suggestive of nasal polyps, which can occur in chronic rhinosinusitis but are not specific to allergic rhinitis. Nasal polyps are non-cancerous growths that can obstruct nasal passages and cause breathing difficulties.
Choice D rationale
Eye tearing and thick yellow nasal drainage are more characteristic of an infection, such as bacterial sinusitis or conjunctivitis. Allergic rhinitis usually causes clear, watery secretions and may involve eye symptoms like itching and tearing, but not thick yellow drainage.
Correct Answer is C
Explanation
Choice A rationale
Increasing the intake of red meat is not advisable for clients with elevated serum uric acid levels, as red meat is high in purines, which can exacerbate gout symptoms.
Choice B rationale
Splinting the affected joint may provide temporary relief from pain, but it does not address the underlying issue of elevated serum uric acid levels.
Choice C rationale
Encouraging fluid intake is essential for clients with elevated serum uric acid levels, as it helps to dilute the urine and promote the excretion of uric acid, reducing the risk of gout attacks.
Choice D rationale
Measuring urine output is important for monitoring kidney function, but it does not directly address the management of elevated serum uric acid levels.