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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Paresthesia: Paresthesia refers to abnormal sensations such as tingling, pricking, or numbness, typically without an external stimulus. The client's ability to discriminate two points at specific distances on the fingertips and palms does not indicate abnormal sensations or paresthesia.

B) Rebound reaction to the needle points: A rebound reaction would involve a delayed response or heightened sensitivity following the removal of a stimulus. This test does not measure rebound reactions but rather the ability to discriminate two separate points.

C) Normal sensory finding: The ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination. The fingertips typically have a higher density of sensory receptors and thus can discriminate smaller distances between two points, whereas the palms have fewer receptors and require a greater distance to discern two points.

D) Marginal decline in sensory function: The described ability to sense two points at these specific distances does not indicate a decline in sensory function. It aligns with normal findings for a middle-aged adult.

A. Continue with the remainder of the client's physical assessment. B. Report the client's abnormal lung sounds to the healthcare provider. C. Ask the client to cough and then auscultate at the site again. D. Measure the client's oxygen saturation with a pulse oximeter.

Correct Answer is A

Explanation

A) Continue with the remainder of the client's physical assessment:
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, there is no immediate concern or need for further action related to this finding. The nurse should continue with the remainder of the client's physical assessment.

B) Report the client's abnormal lung sounds to the healthcare provider:
Vesicular breath sounds are considered normal lung sounds and do not warrant reporting as abnormal. Reporting this finding to the healthcare provider would not be appropriate and may lead to unnecessary concern or intervention.

C) Ask the client to cough and then auscultate at the site again:
Coughing would not be necessary in response to hearing vesicular breath sounds, as these are normal lung sounds. Repeating the auscultation may not provide additional information beyond confirming the presence of normal breath sounds.

D) Measure the client's oxygen saturation with a pulse oximeter:
Measuring oxygen saturation with a pulse oximeter is not indicated in response to hearing vesicular breath sounds. These breath sounds are normal and do not necessarily indicate a problem with oxygenation. Therefore, measuring oxygen saturation would not be the appropriate action in this situation.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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