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 D

Explanation

Choice A rationale
Checking distal phalanges capillary refill assesses circulation but does not specifically identify findings consistent with paresthesia.
Choice B rationale
Evaluating the client’s muscle strength and hand grips assesses motor function but not sensory changes associated with paresthesia.
Choice C rationale
Reviewing the client’s serum electrolytes can provide information about potential causes of paresthesia but does not directly identify sensory findings.
Choice D rationale
Observing the skin for erythema, edema, and warmth can help identify additional findings consistent with paresthesia, such as inflammation or nerve irritation.

A. Sorting a collection of socks. B. Opening a bar soap package. C. Telephoning a family member. D. Reading a short paragraph.

Correct Answer is B

Explanation

Choice A rationale
Sorting a collection of socks may assess cognitive function and fine motor skills, but it does not directly evaluate the ability to perform activities of daily living (ADL) such as bathing, dressing, or feeding.
Choice B rationale
Opening a bar soap package is a practical task that requires fine motor skills and dexterity, which are essential for performing activities of daily living (ADL) such as bathing and grooming.
Choice C rationale
Telephoning a family member assesses communication skills and cognitive function but does not directly evaluate the ability to perform activities of daily living (ADL)3.
Choice D rationale
Reading a short paragraph assesses cognitive function and literacy skills but does not directly evaluate the ability to perform activities of daily living (ADL)3.

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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

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?

Correct Answer is D

Explanation

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

Correct Answer is B

Explanation

When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

An older male client reports to the nurse that his feet are cold. Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.

During an admission assessment, which approach should the nurse use to assess a client’s speech patterns?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?