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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Correct Answer is C

Explanation

Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.

A. Ask the client if he knows the year he married his wife. B. Determine if the client can recall what he ate for breakfast. C. Instruct the client to follow a three-step task. D. Tell the client to repeat a series of unrelated numbers.

Correct Answer is C

Explanation

Choice A rationale
Asking the client if he knows the year he married his wife assesses long-term memory, not recent memory.
Choice B rationale
Determining if the client can recall what he ate for breakfast assesses recent memory but does not provide a comprehensive assessment.
Choice C rationale
Instructing the client to follow a three-step task assesses the client’s ability to process and remember recent information, providing a more thorough evaluation of recent memory.
Choice D rationale
Telling the client to repeat a series of unrelated numbers assesses short-term memory and attention, not specifically recent memory.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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?

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