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","D"]

Explanation

Choice A rationale
The right side of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Choice B rationale
The center of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Choice C rationale
The apex of the heart is where S1 is loudest. S1 is caused by the closure of the mitral and tricuspid valves and is best heard at the apex.
Choice D rationale
The base of the heart is where S2 is loudest. S2 is caused by the closure of the aortic and pulmonic valves and is best heard at the base.
Choice E rationale
The left side of the heart is not specifically associated with the loudest heart sounds for S1 or S213.

A. Ask the client to complete a common proverb or saying. B. Have the client repeat a phrase containing alliteration. C. Note the client’s responses during the initial interview. D. Listen while the client reads items listed on the menu.

Correct Answer is C

Explanation

Choice A rationale
Asking the client to complete a common proverb or saying can provide some insight into cognitive function and language skills, but it may not comprehensively assess speech patterns. This method may also be influenced by the client’s familiarity with specific proverbs.
Choice B rationale
Having the client repeat a phrase containing alliteration can assess specific aspects of speech, such as articulation and fluency. However, it may not provide a holistic assessment of speech patterns and may not be suitable for all clients.
Choice C rationale
Noting the client’s responses during the initial interview allows the nurse to observe the client’s spontaneous speech patterns, including articulation, fluency, rate, and coherence, during the natural flow of conversation. This approach provides a comprehensive assessment of speech abilities in various contexts.
Choice D rationale
Listening while the client reads items listed on the menu can assess reading ability and pronunciation, but it may not fully capture speech patterns in spontaneous conversation or communication. Additionally, it may not be relevant to clients who may have difficulty reading or have limited literacy skills.

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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

Heart sounds are loudest for S1 at the ______ and S2 at the _____.

Correct Answer is ["C","D"]

Explanation

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

Correct Answer is C

Explanation

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