A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Intranasal edema and swelling of turbinates.

Eye tearing and thick yellow nasal drainage.

Purulent secretions from eyes and nares.

Snoring and bilateral, pale gray nodules.

Answer and Explanation

The Correct Answer is A

A) Intranasal edema and swelling of turbinates:
Allergic rhinitis is characterized by inflammation of the nasal mucosa in response to allergen exposure. This inflammation leads to symptoms such as nasal congestion, sneezing, and rhinorrhea. Intranasal edema and swelling of the turbinates are common findings in allergic rhinitis due to the body's immune response to allergens.

B) Eye tearing and thick yellow nasal drainage:
Eye tearing and thick yellow nasal drainage are more indicative of a bacterial infection rather than allergic rhinitis. In allergic rhinitis, nasal discharge is typically clear and watery.

C) Purulent secretions from eyes and nares:
Purulent secretions from the eyes and nares suggest a bacterial infection rather than allergic rhinitis. Allergic rhinitis typically presents with clear nasal discharge, while purulent secretions are more commonly associated with bacterial sinusitis or conjunctivitis.

D) Snoring and bilateral, pale gray nodules:
Snoring and bilateral, pale gray nodules are not characteristic findings of allergic rhinitis. Snoring may be associated with nasal congestion, but pale gray nodules are not typically observed in allergic rhinitis. These findings may indicate other nasal or upper airway conditions such as nasal polyps or adenoid hypertrophy.

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Correct Answer is C

Explanation

A) Paresthesia: Paresthesia refers to abnormal sensations such as tingling, pricking, or numbness, typically without an external stimulus. The client's ability to discriminate two points at specific distances on the fingertips and palms does not indicate abnormal sensations or paresthesia.

B) Rebound reaction to the needle points: A rebound reaction would involve a delayed response or heightened sensitivity following the removal of a stimulus. This test does not measure rebound reactions but rather the ability to discriminate two separate points.

C) Normal sensory finding: The ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination. The fingertips typically have a higher density of sensory receptors and thus can discriminate smaller distances between two points, whereas the palms have fewer receptors and require a greater distance to discern two points.

D) Marginal decline in sensory function: The described ability to sense two points at these specific distances does not indicate a decline in sensory function. It aligns with normal findings for a middle-aged adult.

A. Ask the client to describe any other related symptoms. B. Place the dorsum of the hand on the client's forehead. C. Use both hands to hold and palpate the client's hands. D. Lightly pinch a fold of skin over the client's sternum.

Correct Answer is B

Explanation

Answer: B. Place the dorsum of the hand on the client's forehead.

Rationale:

A) Ask the client to describe any other related symptoms.
While asking the client about symptoms related to fever, such as chills or sweating, can provide useful subjective information, it is not a reliable or objective method to confirm fever. Direct temperature measurement is needed for confirmation.

B) Place the dorsum of the hand on the client's forehead.
Placing the dorsum (back) of the hand on the client’s forehead is a common method to assess skin temperature. While this action provides a quick, non-invasive estimation of whether the client feels warm, it still requires confirmation with an actual temperature measurement using a thermometer for an objective assessment.

C) Use both hands to hold and palpate the client's hands.
Palpating the client's hands may provide information about extremity temperature or circulation, but it is not a reliable method for assessing core body temperature or confirming the presence of fever.

D) Lightly pinch a fold of skin over the client's sternum.
Pinching a fold of skin over the sternum assesses skin turgor, which is a measure of hydration and elasticity, not temperature. It does not provide any indication of whether the client has a fever.

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A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

Correct Answer is B

Explanation

Rationale:

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