Question

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse?

a. Cornea are jaundiced.

b. Oral mucosa is cyanotic.

c. Face is flushed and diaphoretic.

d. Eyelids are matted and crusted.

Answer 1

Oral mucosa that is cyanotic is the most critical assessment finding and requires immediate intervention as it indicates a severe oxygen deficit in the bloodstream.

Step-by-step explanation:

In observing a client's face, the assessment finding that requires the most immediate intervention by the nurse is the oral mucosa that is cyanotic. Cyanosis of the oral mucosa indicates a severe lack of oxygen in the bloodstream, which is a medical emergency and requires prompt intervention to address potential respiratory or circulatory failure. This condition is more critical than jaundice, which is a sign of liver dysfunction, or matted and crusted eyelids, which could indicate an infection such as blepharitis, or even a flushed and diaphoretic face, which may indicate fever or other non-emergent issues.