A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?

Acute pain, change in visual acuity, and foreign body sensation.

Frequent burning, irritation and tearing of the eyes.

Bilateral itchy, red eyes with watery discharge.

Diminished ability to focus on close work and excessive illumination required.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Acute pain, change in visual acuity, and foreign body sensation: These symptoms are concerning and require immediate ophthalmologic evaluation. Subconjunctival hemorrhages are usually benign and painless, so the presence of pain, vision changes, and foreign body sensation suggests a more serious underlying ocular injury or pathology.

B. Frequent burning, irritation and tearing of the eyes: These symptoms are commonly associated with dry eye syndrome or minor irritations. While uncomfortable, they do not typically indicate an urgent need for specialist referral unless severe or persistent.

C. Bilateral itchy, red eyes with watery discharge: This presentation is most consistent with allergic conjunctivitis. Although it may warrant treatment, it is not typically emergent and does not usually require urgent evaluation by an ophthalmologist.

D. Diminished ability to focus on close work and excessive illumination required: These are classic signs of presbyopia, an age-related decline in near vision. Presbyopia is a gradual process and not an emergency that requires immediate referral for urgent evaluation.

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Correct Answer is B

Explanation

Rationale:
A. Measure the circumference of the calf: Measuring calf circumference is used primarily to assess for deep vein thrombosis (DVT) or edema, not dehydration. It evaluates for swelling but does not give information about the client’s hydration status.

B. Grasp skin fold of the posterior forearm: Checking skin turgor by grasping and gently pulling a fold of skin on the posterior forearm is a standard method to assess for dehydration. Poor turgor, where the skin remains tented, suggests fluid volume deficit and supports a diagnosis of dehydration.

C. Check hands for parchment-like appearance: A parchment-like appearance of the hands is more related to normal aging changes rather than acute dehydration. It reflects thinning of the skin rather than fluid status, and could lead to misinterpretation if used for hydration assessment.

D. Press skin over a bony prominence: Pressing over bony prominences checks for edema or pitting rather than skin elasticity. While edema can coexist with dehydration in complex cases, evaluating turgor is a more direct and sensitive technique for diagnosing dehydration.

A. Soft tissue. B. Full bladder. C. Intestinal mass. D. Gas.

Correct Answer is D

Explanation

Rationale:
A. Soft tissue: Percussing over soft tissue typically produces a dull sound rather than a high-pitched, musical tone. Soft tissues like muscle and solid organs absorb sound, creating a muted percussion note.

B. Full bladder: A full bladder will produce a dull sound upon percussion because it is a fluid-filled structure. Dullness rather than high-pitched resonance would be expected over a distended bladder.

C. Intestinal mass: An intestinal mass would also result in a dull percussion note because solid structures or tumors absorb sound waves rather than producing a resonant or musical tone.

D. Gas: Gas within the intestines causes a tympanic, musical, high-pitched sound on percussion. This finding is normal over air-filled bowel loops and indicates the presence of intestinal gas.

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A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which focused assessment technique should the nurse use for a client admitted with possible dehydration?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?