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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a reason:
Educational Prevention is not a recognized level of prevention in healthcare. While education is a key component in all levels of prevention, it is not a standalone category. Education is typically included in primary prevention as it involves informing the public about health practices to prevent the onset of disease.
Choice b reason:
Tertiary Prevention is the level of prevention that aims to manage and treat an existing disease to prevent further complications or deterioration. In the case of immobile stroke patients, tertiary prevention would involve measures to prevent skin breakdown and other complications associated with immobility and the stroke's long-term effects.
Choice c reason:
Secondary Prevention involves early detection and prompt intervention to prevent the progression of a disease. For stroke patients, secondary prevention might include monitoring for signs of skin breakdown so that early treatment can be initiated. However, the scenario described focuses on managing an existing condition rather than early detection.
Choice d reason:
Primary Prevention aims to prevent the disease or injury before it occurs. This would involve strategies to prevent strokes in the first place, such as controlling high blood pressure or encouraging healthy lifestyle changes. It does not directly relate to the prevention of skin breakdown in patients who have already had a stroke.
Correct Answer is B
Explanation
Choice a reason:
Immunization schedules are typically considered a part of primary prevention. They are intended to prevent diseases before they occur by using vaccines to provide immunity against infections.
Choice b reason:
Regular mammogram screenings are a form of secondary prevention. They are used to detect breast cancer lesions early before symptoms appear, which can lead to more effective treatment and better outcomes.
Choice c reason:
The consistent use of seat belts is a primary prevention strategy. It is a proactive measure to prevent injuries in the event of a motor vehicle accident.
Choice d reason:
Annual vision examinations can be considered part of secondary prevention if they are used to detect vision problems or eye diseases in their early stages. However, they can also be seen as primary prevention because they help maintain and protect eye health before issues arise.
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