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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.

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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A. Check distal phalanges capillary refill. B. Evaluate client’s muscle strength and hand grips. C. Review the client’s serum electrolytes. D. Observe skin for erythema, edema, and warmth. E. Observe skin for erythema, edema, and warmth.

Correct Answer is D

Explanation

Choice A rationale

Checking distal phalanges capillary refill assesses circulation but does not specifically identify findings consistent with paresthesia.

Choice B rationale

Evaluating the client’s muscle strength and hand grips assesses motor function but not sensory changes associated with paresthesia.

Choice C rationale

Reviewing the client’s serum electrolytes can provide information about potential causes of paresthesia but does not directly identify sensory findings.

Choice D rationale

Observing the skin for erythema, edema, and warmth can help identify additional findings consistent with paresthesia, such as inflammation or nerve irritation.

A. Painful symptoms alleviated by warmth. B. Cool, pale skin below the knees. C. Decreased pain when legs are elevated. D. Deep, continuous pain in the calf muscles.

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.

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

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?

Correct Answer is D

Explanation

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Correct Answer is C

Explanation

While completing an admission assessment, the nurse is unable to palpate the client’s left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

While auscultating a client’s abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which querry should the nurse ask first?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

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