A middle-aged school teacher complains of excessive tearing of the eyes every morning. Which assessment should the nurse perform next?

Assess the nasolacrimal sac

Inspect the palpebral conjunctiva

Test pupillary reaction to light

Perform the eye positions test

Answer and Explanation

The Correct Answer is A

Choice A Reason:
The nasolacrimal sac is part of the tear drainage system. When a patient presents with excessive tearing, known as epiphora, it is important to assess for any obstruction in the lacrimal apparatus. The nasolacrimal sac can become blocked due to various reasons such as infection, inflammation, or structural abnormalities. Assessing this area can help determine if there is a blockage causing the tears to accumulate and overflow.

Choice B Reason:
Inspecting the palpebral conjunctiva is typically done if there is a complaint of eye pain or a sensation of a foreign body in the eye. While it is part of a comprehensive eye examination, it is not the first assessment to be performed for excessive tearing unless there are additional symptoms that suggest a problem with the conjunctiva.

Choice C Reason:
Testing the pupillary reaction to light is an assessment of the pupillary response and the function of the oculomotor nerve. This test is crucial when neurological issues are suspected or if there is a change in vision. However, it is not the primary assessment for excessive tearing without other associated symptoms.

Choice D Reason:
The eye positions test, which assesses eye muscle strength and cranial nerve function, is not necessary unless there are signs of problems with muscle strength, such as drooping. This test would not typically be the next step in assessing a patient with excessive tearing unless there are other indications of muscle or nerve impairment.

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Correct Answer is B

Explanation

Choice a reason:
A client recently diagnosed with a chronic illness would require a comprehensive health history that includes past medical history, medications, and lifestyle factors. While important, it is not typically categorized as an emergency health history unless the chronic condition has acutely worsened.

Choice b reason:
A client presenting with hypotension (low blood pressure), tachycardia (rapid heart rate), an oxygen saturation of 85% (indicating potential hypoxemia), and a recent gunshot wound is experiencing a life-threatening situation that requires immediate medical attention. An Emergency health history is crucial in this scenario to quickly gather information that will guide urgent treatment decisions.

Choice c reason:
A client who has just confirmed pregnancy would need a detailed health history, including obstetric and gynecological history, but this is not considered an emergency unless there are complications or concerns that require immediate attention.

Choice d reason:
A client who frequently visits the hospital reporting the same symptom may indicate a chronic issue that needs ongoing management rather than an emergency. However, if the symptom suggests an acute exacerbation or a new, serious condition, it could escalate to an emergency.

A. Wear nonslip shoes in the house. B. Use of guns should be supervised by an adult. C. Always use seat belts. D. Avoid risky activities such as snowboarding.

Correct Answer is ["A","B","C","D"]

Explanation

Choice a reason:
Wearing nonslip shoes in the house can prevent falls, which are a common cause of traumatic brain injuries (TBIs) in adolescents. Falls often occur due to slippery surfaces, and nonslip shoes provide better traction, reducing the risk of such accidents.
Choice b reason:
Supervised use of guns by an adult is crucial to prevent accidental shootings, which can result in TBIs or even more severe outcomes. Adolescents may not fully understand the risks associated with handling firearms, and adult supervision ensures that safety measures are followed.
Choice c reason:
The consistent use of seat belts in vehicles is one of the most effective ways to prevent TBIs during car accidents. Seat belts keep occupants from being ejected or hitting the interior of the car, significantly reducing the risk of head injuries.
Choice d reason:
Avoiding risky activities such as snowboarding without proper safety measures can prevent sports-related TBIs. While snowboarding, wearing a helmet and other protective gear is essential to protect the head during falls or collisions.

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A middle-aged school teacher complains of excessive tearing of the eyes every morning. Which assessment should the nurse perform next?

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Naxlex Comprehensive Predictor Exams

The student nurse is reviewing different types of health history. Which client situation would require an Emergency health history?

Correct Answer is B

Explanation

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

Correct Answer is ["A","B","C","D"]

Explanation

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