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
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.
Correct Answer is B
Explanation
Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.