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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Mucous Membranes:
In clients with dark skin, mucous membranes such as the lips, tongue, and gums are the best sites to assess for cyanosis. These areas have less pigmentation and are more vascular, allowing for a more accurate evaluation of oxygenation and the presence of cyanosis.
B. Dorsal surface of the hand:
The dorsal surface of the hand can be used to assess for cyanosis in lighter-skinned individuals, but it is less reliable in dark-skinned clients due to the higher melanin content, which can obscure the bluish tint indicative of cyanosis.
C. Dorsal surface of the foot:
Similar to the dorsal surface of the hand, the dorsal surface of the foot is not an ideal site for assessing cyanosis in clients with dark skin. The presence of melanin can make it difficult to detect changes in skin color.
D. Pinnae of the ears:
The pinnae of the ears are also not the best sites for assessing cyanosis in dark-skinned clients. These areas can be highly pigmented, which can mask the bluish discoloration associated with cyanosis. The mucous membranes remain the most reliable site for this assessment.
Correct Answer is B
Explanation
(a) Soles of the feet:
The soles of the feet are not considered the most reliable indicator of central cyanosis because peripheral areas can be affected by various factors, including temperature and circulation. Changes in color here might not accurately reflect central oxygenation status.
(b) Oral mucosa:
The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation status of the central circulatory system. Cyanosis in this area indicates a significant drop in arterial oxygen saturation and is a more direct indicator of hypoxemia compared to peripheral sites.
(c) Ear lobes:
Ear lobes, like the soles of the feet, can be influenced by peripheral circulation and environmental factors. While cyanosis can be observed here, it is not as reliable as central sites like the oral mucosa for assessing systemic oxygenation.
(d) Conjunctivae:
The conjunctivae can show signs of cyanosis, but the oral mucosa is still a more sensitive and reliable indicator for central cyanosis. The oral mucosa provides a clear and consistent site to assess oxygenation in emergency situations.
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