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
Working in a day care center may expose the client to minor injuries or infections, but it is not directly associated with widespread ecchymosis. Ecchymosis is more likely related to systemic issues rather than occupational hazards.
Choice B rationale
Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. Ecchymosis is not a typical manifestation of gluten intolerance.
Choice C rationale
Taking an oral anticoagulant medication increases the risk of bleeding, which can manifest as ecchymosis (bruising) on the skin. Anticoagulants such as warfarin or aspirin can interfere with the blood’s ability to clot, leading to bleeding into the skin and subsequent ecchymosis.
Choice D rationale
Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities.

A. Pupils equal, round, reacts to light (PERRL). B. Neurological status intact. C. Pupils equal, round, reacts to light, and accommodation (PERLA). D. Glasgow Coma Scale (GCS) of 15.

Correct Answer is A

Explanation

Choice A rationale
Pupils equal, round, and reactive to light (PERRL) accurately summarizes the findings of the pupillary assessment. It indicates that both pupils are equal in size, round in shape, and react briskly to light, which is a normal finding.
Choice B rationale
Documenting “neurological status intact” is too vague and does not specifically describe the pupillary assessment findings.
Choice C rationale
Pupils equal, round, reactive to light, and accommodation (PERLA) includes an additional assessment of accommodation, which was not mentioned in the scenario.
Choice D rationale
The Glasgow Coma Scale (GCS) of 15 is a general assessment of consciousness and does not specifically describe the pupillary findings.

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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

When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

Correct Answer is C

Explanation

When performing a neurologic assessment on an alert client, the nurse observes that the client’s pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

Correct Answer is A

Explanation

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