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 D

Explanation

A. Number of blood clots expelled with each stool:
While the number of blood clots expelled with each stool may be relevant in assessing the severity of bleeding, it does not provide as much information about the potential underlying causes of bleeding as documenting the color characteristics of the stool does. Therefore, although it may be noted, it is not the most crucial aspect to document initially.

B. Evidence of internal hemorrhoids:
Documenting evidence of internal hemorrhoids is important in assessing rectal bleeding, but it is not as fundamental as documenting the color characteristics of the stool. Internal hemorrhoids can be one potential cause of rectal bleeding, but other more serious conditions may also cause bleeding, so a comprehensive assessment of the stool is necessary.

C. Unique odor noted with gastrointestinal bleeding:
While gastrointestinal bleeding may have a distinct odor, documenting this alone does not provide as much diagnostic information as describing the color characteristics of the stool. Documenting odor may be important in some cases, but it is not as critical as documenting the color of the stool, which can help identify potential causes of bleeding.

D. Color characteristics of each stool:
When evaluating rectal bleeding, documenting the color characteristics of each stool is crucial. Different colors of stool can indicate various underlying causes of bleeding. Bright red blood typically suggests lower gastrointestinal bleeding, while darker, tarry stools (melena) may indicate bleeding higher in the gastrointestinal tract. Describing the color, consistency, and presence of any abnormal substances in the stool helps healthcare providers assess the severity and potential causes of the bleeding.

A. Encourage fluid intake. B. Measure urine output. C. Splint the affected joint. D. Increase intake of red meat.

Correct Answer is A

Explanation

A. Encourage fluid intake:
Encouraging fluid intake is the most appropriate action for the client experiencing gout, as it helps to promote the excretion of uric acid through urine. Increased fluid intake can help prevent the formation of urate crystals in the joints and reduce the severity and frequency of gout attacks. It is a fundamental aspect of managing gout and preventing future episodes.

B. Measure urine output:
While monitoring urine output is important for overall assessment, it is not specifically indicated in the management of acute gout attacks. Gout is primarily managed by addressing hyperuricemia and reducing inflammation in the affected joints, which is best achieved through hydration and pharmacological interventions.

C. Splint the affected joint:
Splinting the affected joint may provide some relief by immobilizing it and reducing movement, but it does not address the underlying cause of gout or promote the excretion of uric acid. Splinting is more commonly used in the management of injuries or conditions that require joint stabilization.

D. Increase intake of red meat:
Increasing intake of red meat is contraindicated in clients with gout because red meat contains high levels of purines, which can exacerbate hyperuricemia and increase the risk of gout attacks. Dietary modifications for gout typically involve reducing the consumption of foods high in purines, such as red meat, organ meats, and certain seafood.

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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

When evaluating a client's rectal bleeding, which findings should the nurse document?

Correct Answer is D

Explanation

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Correct Answer is A

Explanation

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