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 D

Explanation

Choice a reason:
Pigeon Chest, or pectus carinatum, is a condition where the breastbone is pushed outward, and the chest appears to protrude. It is not typically associated with a barrel-shaped chest, which is characterized by a rounded and bulging appearance.

Choice b reason:
Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus. While it can cause chest expansion, it does not lead to a barrel-shaped chest. The barrel-shaped chest is more indicative of a chronic condition rather than an acute infection like pneumonia.

Choice c reason:
Funnel Chest, or pectus excavatum, is a condition where the breastbone is sunken into the chest. Unlike a barrel-shaped chest, funnel chest gives the chest a depressed appearance.

Choice d reason:
COPD, or Chronic Obstructive Pulmonary Disease, is commonly associated with a barrel-shaped chest. This shape results from the chronic hyperinflation of the lungs due to obstructive lung disease, which causes the rib cage to remain expanded.

A. Reddened intact skin. B. Skin loss involving up to the subcutaneous tissue (fat). C. Skin loss involving up to the dermis layer. D. Exposed bone.

Correct Answer is B

Explanation

Choice A reason:

Reddened intact skin is typically associated with a stage 1 pressure ulcer, where the skin is not yet broken but shows signs of redness. This stage indicates that the skin is under pressure and may be at risk for further breakdown if the pressure is not relieved.

Choice B reason:

A stage 3 pressure ulcer involves full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer presents as a deep crater, and there may be slough or eschar present. It is important to manage these ulcers carefully to prevent further deterioration and complications such as infection.

Choice C reason:

Skin loss involving up to the dermis layer is characteristic of a stage 2 pressure ulcer. In this stage, the epidermis and part of the dermis are lost, creating a shallow open wound or blister. This stage is less severe than stage 3 and requires different management strategies to promote healing and prevent progression.

Choice D reason:

Exposed bone is indicative of a stage 4 pressure ulcer, which is the most severe stage. It involves full-thickness skin loss with extensive destruction, possibly including muscle, tendon, or bone exposure. These ulcers are at high risk for serious infections, including osteomyelitis, and require aggressive medical and surgical intervention to heal.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While examining a client, the nurse observes the client's chest to be barrel-shaped. The nurse would interpret this as indicating which of the following?

Correct Answer is D

Explanation

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer is B

Explanation

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

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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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