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?

Purulent secretions from eyes and nares.

Snoring and bilateral, pale gray nodules.

Intranasal edema and swelling of turbinates.

Eye tearing and thick yellow nasal drainage.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Purulent secretions from eyes and nares is incorrect. Purulent secretions, which are thick and yellow or green in color, typically indicate the presence of a bacterial infection rather than allergic rhinitis. Allergic rhinitis is more commonly associated with clear nasal discharge, although it can sometimes be accompanied by a mild increase in nasal secretions.
Choice B Reason:
Snoring and bilateral, pale gray nodules is incorrect. Snoring and bilateral, pale gray nodules suggest adenoid hypertrophy rather than allergic rhinitis. Adenoid hypertrophy refers to enlargement of the adenoids, which are lymphoid tissue located in the back of the nasal cavity. Enlarged adenoids can lead to snoring and the presence of grayish nodules upon examination of the nasopharynx.
Choice C Reason:
Intranasal edema and swelling of turbinates are correct. Intranasal edema (swelling inside the nose) and swelling of turbinates are characteristic features of allergic rhinitis. Allergic rhinitis results from inflammation of the nasal mucosa in response to exposure to allergens, leading to nasal congestion and swelling of the turbinates.
Choice D Reason:
Eye tearing and thick yellow nasal drainage is incorrect. Eye tearing and thick yellow nasal drainage suggest the presence of sinusitis rather than allergic rhinitis. Sinusitis is characterized by inflammation of the sinuses, which can result in symptoms such as facial pain or pressure, thick nasal discharge, and eye tearing due to sinus pressure affecting the tear ducts.

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Correct Answer is A

Explanation

Choice A Reason:
Standing directly in front of the client and ask about any hearing loss is appropriate because the client's behavior of ignoring questions from the nurse and speaking loudly to her son suggests a potential hearing impairment. Standing directly in front of the client allows for better visibility of facial expressions and lip movements, which can aid in communication for individuals with hearing loss. Asking about any hearing loss helps the nurse gather important information to adapt communication strategies effectively.
Choice B Reason:
Obtaining a tuning fork to complete Rinne and Weber tuning fork tests involves conducting hearing tests using a tuning fork to assess for conductive or sensorineural hearing loss. While these tests are valuable for diagnosing hearing impairments, they are typically performed after obtaining a thorough history and initial assessment, including asking about any hearing loss. Therefore, this option is not the first action to take when communication difficulties are observed.
Choice C Reason:
Beginning to orient the client to her surroundings in the hospital room involves providing orientation to the client about her surroundings, which is important for promoting comfort and reducing anxiety, especially in a new environment like a hospital room. However, addressing potential hearing loss is the priority when the client's behavior suggests difficulty in communication. Once hearing impairment is ruled out or addressed, orientation to the surroundings can be initiated.
Choice D Reason:
Performing a mental status exam to assess the client's thought processes involves assessing the client's cognitive function and thought processes, which is important for understanding the client's overall mental status. While assessing mental status is an essential aspect of comprehensive nursing assessment, it may not directly address the observed communication difficulties related to potential hearing impairment. Therefore, addressing potential hearing loss should be the first action to ensure effective communication before proceeding with a mental status exam.

A. White blood cell count (WBC). B. Glucose. C. Blood urea nitrogen (BUN). D. Hematocrit.

Correct Answer is D

Explanation

Choice A Reason:
White blood cell count (WBC) is inappropriate. White blood cell count is typically monitored to assess for signs of infection or inflammation. While it's important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection. Therefore, monitoring WBC count may not be the most immediate response to the finding of melena.
Choice B Reason:
Glucose is inappropriate. Glucose monitoring is essential for patients with diabetes or those at risk of hypoglycemia or hyperglycemia. However, melena is not directly related to glucose metabolism or regulation. Therefore, monitoring glucose levels would not be the most relevant response to the finding of melena.
Choice C Reason:
Blood urea nitrogen (BUN) is inappropriate. Blood urea nitrogen is often monitored to assess kidney function and hydration status. While severe bleeding can potentially lead to hypovolemia and prerenal azotemia (elevated BUN due to decreased renal perfusion), monitoring BUN would not be the immediate response to the finding of melena. Instead, assessing for signs of hypovolemia and monitoring other markers of blood loss, such as hematocrit, would be more appropriate.
Choice D Reason:
Hematocrit is appropriate. Melena refers to the passage of black, tarry stools containing blood that has been digested. It indicates upper gastrointestinal bleeding, typically from the stomach or upper small intestine. Monitoring the hematocrit level is important because significant bleeding, as indicated by melena, can lead to a decrease in the hematocrit level due to the loss of red blood cells and plasma volume. Monitoring the hematocrit helps assess the severity of the bleeding and guides treatment decisions, such as the need for blood transfusions. Therefore, the nurse should monitor the hematocrit level in response to the finding of melena.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Correct Answer is A

Explanation

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is D

Explanation

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