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

Assess the nasolacrimal sac

Test pupillary reaction to light

Inspect the palpebral conjunctiva

Perform the eye positions test

Answer and Explanation

The Correct Answer is A

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A) Location: Documenting the exact location of lesions is crucial for monitoring changes over time, assessing potential spread or resolution, and providing accurate information for future reference. This information helps in the diagnosis and in tracking the effectiveness of treatments.

B) Color: The color of lesions can provide important clues about their nature and cause. For example, red or inflamed lesions might indicate infection or irritation, while darker lesions could suggest malignancy or chronicity. Color changes can also signify healing or worsening of the lesion.

C) Condition of surrounding skin: Noting the condition of the skin around the lesions helps assess whether there is additional inflammation, infection, or other skin conditions that may be related to the primary lesion. This provides a more comprehensive understanding of the patient’s skin health and any secondary complications.

D) Elevation: Elevation refers to whether the lesion is raised, flat, or depressed compared to the surrounding skin. This characteristic helps in identifying the type of lesion, such as a papule, plaque, or ulcer. Elevated lesions might suggest certain dermatological conditions, while depressed lesions might indicate scarring or loss of tissue.

E) Distribution pattern: The pattern of how lesions are distributed on the body can provide diagnostic clues. For example, a linear distribution might suggest contact dermatitis, while a symmetrical distribution could indicate a systemic condition. Understanding the distribution pattern helps in identifying the underlying cause and planning appropriate treatment.

A. Liver Disease B. Diabetes mellitus C. End Stage Renal Disease D. Colon Cancer

Correct Answer is A

Explanation

(a) Liver Disease:

Pitting edema is commonly seen in liver disease, especially in conditions like cirrhosis. Liver disease can lead to hypoalbuminemia, where low levels of albumin in the blood cause fluid to leak into the interstitial spaces, resulting in edema. Additionally, liver disease often leads to portal hypertension, which can also contribute to the development of edema.

(b) Diabetes mellitus:

While diabetes can cause complications such as diabetic nephropathy, which may lead to fluid retention, pitting edema is not a primary symptom directly associated with diabetes mellitus. Diabetic patients may develop edema due to kidney issues, but it is not as directly associated as with liver disease.

End-stage renal disease (ESRD) can indeed cause significant fluid retention and edema, including pitting edema. The kidneys' inability to excrete excess fluid leads to its accumulation in tissues. However, the question seems to point towards liver disease, which directly leads to conditions causing pitting edema.

(d) Colon Cancer:

Colon cancer is not typically associated with pitting edema. While advanced cancer can lead to various complications, including fluid imbalances, it is not a primary cause of pitting edema. Edema related to cancer is often more localized and associated with tumor sites or treatment areas.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

In which disease process should a nurse expect to see a client with the presence of pitting edema?

Correct Answer is A

Explanation

The nurse read the patient's health history cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

During your physical examination of a 29-year-old professional volley ball player who recently completed a beach tournament, you gently pinch the skin on the chest area. The skin remains in a "tent" shape and slowly returns to its normal position. This is a sign of

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

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?

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?