While observing a client's face, which assessment finding requires immediate intervention by the nurse?
Face is flushed and diaphoretic.
Eyelids are matted and crusted.
Cornea are jaundiced.
Oral mucosa is cyanotic.
The Correct Answer is D
A) Face is flushed and diaphoretic:
While flushing and diaphoresis can indicate fever, anxiety, or other conditions, they do not typically require immediate intervention unless associated with other severe symptoms.
B) Eyelids are matted and crusted:
Matted and crusted eyelids may indicate an eye infection, such as conjunctivitis, which requires treatment but not immediate emergency intervention.
C) Cornea are jaundiced:
Jaundiced corneas (scleral icterus) suggest elevated bilirubin levels and possible liver dysfunction. This finding requires prompt evaluation but is not typically an emergency requiring immediate intervention.
D) Oral mucosa is cyanotic:
Cyanosis of the oral mucosa indicates a lack of oxygen in the blood and is a sign of hypoxemia or respiratory distress. This is a critical finding that requires immediate intervention to address potential life-threatening respiratory or cardiovascular issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Face is flushed and diaphoretic:
While flushing and diaphoresis can indicate fever, anxiety, or other conditions, they do not typically require immediate intervention unless associated with other severe symptoms.
B) Eyelids are matted and crusted:
Matted and crusted eyelids may indicate an eye infection, such as conjunctivitis, which requires treatment but not immediate emergency intervention.
C) Cornea are jaundiced:
Jaundiced corneas (scleral icterus) suggest elevated bilirubin levels and possible liver dysfunction. This finding requires prompt evaluation but is not typically an emergency requiring immediate intervention.
D) Oral mucosa is cyanotic:
Cyanosis of the oral mucosa indicates a lack of oxygen in the blood and is a sign of hypoxemia or respiratory distress. This is a critical finding that requires immediate intervention to address potential life-threatening respiratory or cardiovascular issues.
Correct Answer is B
Explanation
Answer: B. Opening a bar soap package.
Rationale:
A) Telephoning a family member:
Using a telephone is considered an instrumental activity of daily living (IADL), which involves more complex tasks required for independent living, such as managing communication. While important, it does not directly assess the physical and motor skills required for basic self-care.
B) Opening a bar soap package:
Opening a bar soap package involves fine motor skills and hand coordination, which are necessary for performing basic activities of daily living (ADLs). ADLs refer to essential self-care tasks like bathing, dressing, and grooming. Being able to open soap indicates the client has the dexterity needed for personal hygiene.
C) Sorting a collection of socks:
Sorting socks is more cognitive than motor-oriented, and it assesses organization skills, which are more aligned with IADLs rather than ADLs. It does not specifically evaluate the client’s ability to perform tasks related to basic self-care.
D) Reading a short paragraph:
Reading a paragraph evaluates literacy or cognitive function but is not directly related to performing ADLs. ADLs focus on physical activities necessary for daily living, such as dressing, eating, or bathing.
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