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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 B

Explanation

Choice A rationale

Placing a mark where the DP pulse is auscultated can help in future assessments but does not address the immediate need to locate the pulse.

Choice B rationale

Using a Doppler to assess an audible DP pulse is the correct answer. A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable.

Choice C rationale

Assessing capillary refill distal to the DP pulse is important but should be done after attempting to locate the pulse with a Doppler.

Choice D rationale

Reviewing the client’s history for vascular disease is essential for understanding the underlying cause but does not address the immediate need to locate the pulse.

Correct Answer is C

Explanation

Choice A rationale

Working in a day care center may expose the client to minor injuries or infections, but it is not directly associated with widespread ecchymosis. Ecchymosis is more likely related to systemic issues rather than occupational hazards.


Choice B rationale

Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. Ecchymosis is not a typical manifestation of gluten intolerance.

Choice C rationale

Taking an oral anticoagulant medication increases the risk of bleeding, which can manifest as ecchymosis (bruising) on the skin. Anticoagulants such as warfarin or aspirin can interfere with the blood’s ability to clot, leading to bleeding into the skin and subsequent ecchymosis.

Choice D rationale

Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities.

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