A 75-year-old male who is a chronic alcoholic present to the medical office for his annual wellness visit. How would describe the findings found in photo?

Acanthosis Nigricans

Cyanosis

Jaundice

Carotenemia

Answer and Explanation

The Correct Answer is C

A. Acanthosis Nigricans:

Acanthosis nigricans is characterized by dark, velvety patches of skin, often found in body folds such as the neck, armpits, and groin. It does not present as the yellow discoloration seen in the photo.

B. Cyanosis:

Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. The image shows yellow discoloration, not the blue tint associated with cyanosis.

C. Jaundice:

Jaundice is indicated by a yellowish tint to the skin and sclera due to elevated bilirubin levels, commonly associated with liver dysfunction. The photo clearly shows this yellow discoloration, consistent with jaundice, often seen in chronic alcoholics with liver disease.

D. Carotenemia:

Carotenemia presents as a yellow-orange discoloration of the skin, especially on the palms and soles, due to high levels of carotene in the blood. It does not typically affect the sclera, which differentiates it from jaundice. The uniform yellowing of the skin and eyes in the photo aligns more with jaundice.

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Correct Answer is A

Explanation

A) Assess the nasolacrimal sac: Excessive tearing, or epiphora, can result from an obstruction in the nasolacrimal duct, which drains tears from the eye into the nasal cavity. By assessing the nasolacrimal sac, the nurse can determine if there is any blockage or infection causing the excessive tearing, making this the most appropriate next step.

B) Test pupillary reaction to light: While testing pupillary reaction to light is important in a comprehensive eye exam, it does not directly address the issue of excessive tearing. This test is more focused on evaluating neurological function and overall eye health.

C) Inspect the palpebral conjunctiva: Inspecting the palpebral conjunctiva can help identify inflammation, infection, or foreign bodies that may cause discomfort or tearing. However, it does not specifically address the cause of excessive tearing related to nasolacrimal duct obstruction.

D) Perform the eye positions test: The eye positions test assesses extraocular muscle function and cranial nerve integrity. While it is important for a complete eye examination, it is not directly related to the symptom of excessive tearing, which is more likely due to issues with tear drainage.

A. Accessibility B. Food preparation C. Food preferences D. Finances

Correct Answer is A

Explanation

A) Accessibility:

Accessibility refers to the client's ability to obtain food, which is crucial for nutritional status, especially for someone who lives alone and cannot drive. Difficulty in accessing grocery stores or markets can limit the variety and availability of nutritious food options, potentially leading to poor nutritional intake.

B) Food preparation:

Food preparation skills are important, but if the client has difficulty accessing food in the first place (due to transportation limitations), their ability to prepare meals becomes secondary. Accessibility to food sources is a more immediate concern for nutritional status.

C) Food preferences:

While food preferences can influence dietary choices, the ability to access food is a more fundamental issue that directly impacts nutritional intake, especially for someone who lives alone and has limited mobility.

D) Finances:

Financial constraints can certainly affect food choices and access to nutritious options. However, in this scenario, the primary concern is the physical accessibility to food sources, which directly impacts the client's ability to maintain adequate nutrition.

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A 75-year-old male who is a chronic alcoholic present to the medical office for his annual wellness visit. How would describe the findings found in photo?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?

Correct Answer is A

Explanation

A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?

Correct Answer is A

Explanation

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