A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?
Prolonged tonsillar enlargement
History of allergies
Incomplete immunization record
History of epistaxis nosebleeds
The Correct Answer is B
Choice A reason: Prolonged tonsillar enlargement may cause throat issues or obstruction, but rhinorrhea stems from nasal inflammation, not tonsils. This focuses on oropharyngeal anatomy, missing the direct nasal etiology tied to runny nose in upper airway complaints here entirely.
Choice B reason: Allergies trigger nasal inflammation via histamine, causing rhinorrhea as IgE-mediated mast cells release mediators. A history of this is key, directly linking environmental triggers to the client’s runny nose, making it the most relevant assessment area accurately.
Choice C reason: Incomplete immunizations increase infection risk, but rhinorrhea more commonly ties to allergies or viruses than vaccine-preventable diseases here. This is less specific to the symptom’s etiology without fever or systemic signs, reducing its pertinence significantly.
Choice D reason: Epistaxis (nosebleeds) relates to vascular fragility, not mucus production like rhinorrhea. Past bleeding doesn’t explain runny nose, focusing on a separate nasal issue, making it less relevant to the upper airway complaint’s root cause in this case fully.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Brachial pulse, in the upper arm, is strong and palpable in healthy adults, used for blood pressure cuffs. Its deep location ensures consistent detection, unlike weaker pulses, making it reliably felt across most individuals without vascular issues here.
Choice B reason: Ulnar pulse, near the wrist’s pinky side, is often faint or not palpable in many healthy people due to its depth and smaller artery size. This variability distinguishes it as less detectable compared to other major pulses consistently.
Choice C reason: Femoral pulse, in the groin, is robust and palpable in healthy adults, reflecting large artery flow to the legs. Its prominence ensures detection, unlike the ulnar, making it a standard check not commonly absent in normal assessments fully.
Choice D reason: Radial pulse, at the wrist’s thumb side, is easily palpable in healthy clients, a key vital sign check. Its superficial location ensures consistent detection, contrasting with the ulnar’s frequent elusiveness in normal peripheral exams entirely here.
Correct Answer is A
Explanation
Choice A reason: Turning the head against resistance assesses neck muscles, not the temporomandibular joint (TMJ), which hinges the jaw. TMJ evaluation requires jaw-specific movements, not cervical rotation, indicating a misunderstanding of TMJ anatomy and function, misaligning with headache assessment needs.
Choice B reason: Opening the mouth wide while fingers are placed near the ear directly tests TMJ range of motion and joint integrity. This is a standard technique to detect dysfunction or pain, correctly targeting the jaw’s articulation point relevant to headaches.
Choice C reason: Moving the jaw side to side evaluates TMJ lateral excursion, a key diagnostic motion. Pain reporting during this action helps identify joint issues tied to chronic headaches, making it an appropriate and precise instruction for TMJ assessment.
Choice D reason: Pushing out and pulling in the jaw tests TMJ protrusion and retraction, critical for assessing joint stability and sounds like popping, which may link to headache etiology. This instruction correctly focuses on TMJ mechanics and symptoms.
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