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.

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Correct Answer is D

Explanation

A) Electrical cords are placed along the walls: While it is important to ensure that electrical cords are safely managed, cords placed along the walls are less likely to pose a tripping hazard compared to those that are left loose or run across walking paths. This setup, in itself, is generally not a significant safety risk if managed properly.

B) Handrails are present in the bathroom: Handrails in the bathroom are actually a safety feature, not a risk. They provide necessary support for older adults with decreased vision or mobility issues, helping to prevent falls when using the toilet or getting in and out of the bathtub or shower.

C) Uses a microwave for cooking: Using a microwave for cooking is generally considered safe for individuals with decreased vision, as it minimizes the risk of burns and other injuries associated with using a stove or oven. The microwave can be a safer cooking method if the client is familiar with its operation.

D) Scatter rugs are present in the kitchen: Scatter rugs are a significant safety risk, especially for older adults with decreased vision. These rugs can easily cause trips and falls, leading to potentially serious injuries. Removing scatter rugs or securing them with non-slip backing can help mitigate this risk and create a safer home environment.

A. Mucous Membranes B. Dorsal surface of the hand C. Dorsal surface of the foot D. Pinnae of the ears

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.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is A

Explanation

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