A nurse is preparing to assess a client’s conjunctiva.

Identify the sequence the nurse should follow when taking the following actions.

1) Apply examination gloves.

2) Instruct the client to look up.

3) Place the thumbs below each of the client’s lower eyelids.

4) Gently pull the client’s skin down to the top edge of the bony orbital rim.

5) Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions.

1, 2, 3, 4, 5

2, 1, 4, 3, 5

1, 4, 2, 3, 5

2, 3, 1, 4, 5.

Answer and Explanation

The Correct Answer is A

The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva. This is because the nurse should first apply examination gloves to prevent contamination and infection. Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva. Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim. This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions. The sclera should be white and the conjunctiva should be pink.

Choice B is wrong because the nurse should not pull down the skin before instructing the client to look up.

This could cause discomfort and injury to the eye.

Choice C is wrong because the nurse should not instruct the client to look up after pulling down the skin.

This could also cause discomfort and injury to the eye.

Choice D is wrong because the nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.

This could introduce infection and irritants to the eye.

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Correct Answer is D

Explanation

Darkening of the mucosa.This is an expected variation for an older adult client because the melanin production increases with age.

Some possible explanations for the other choices are:

• Choice A.White patches on the tongue could indicate candidiasis, an oral fungal infection.

• Choice B.Bleeding of the gums could indicate gingivitis, periodontitis, or vitamin C deficiency.

• Choice C.Red spots on the hard palate could indicate petechiae, which are small hemorrhages caused by trauma, infection, or bleeding disorders.

Normal ranges for oral mucosa color vary depending on the skin tone and ethnicity of the client.Generally, the oral mucosa should be pink and moist without lesions or discolorations.

A. Normal finding B. Dehydration C. Increased intracranial pressure D. Infection

Correct Answer is A

Explanation

Normal finding.

The anterior fontanelle is the soft spot on the top of an infant’s head that allows for brain growth and skull expansion.

It normally feels soft and flat when the infant is lying down, and may bulge slightly when the infant is sitting up or crying due to increased blood flow and pressure.

This is not a sign of any problem and should be documented as a normal finding.

Dehydration is wrong because dehydration would cause the fontanelle to feel sunken or depressed, not elevated. Dehydration can also cause other signs such as dry mouth, decreased urine output, and lethargy.

Increased intracranial pressure is wrong because increased intracranial pressure would cause the fontanelle to feel tense or bulging at all times, not only when sitting up or crying. Increased intracranial pressure can also cause other signs such as vomiting, irritability, seizures, and altered level of consciousness.

Infection is wrong because infection would cause the fontanelle to feel warm or tender, not elevated. Infection can also cause other signs such as fever, rash, poor feeding, and fussiness.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client’s mouth. The nurse should identify that which of the following is an expected variation for this client?

Correct Answer is D

Explanation

A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying. What should be included in documentation?

Correct Answer is A

Explanation

A nurse is performing a head-to-toe assessment of a newborn. What finding should alert the nurse to a potential problem with the newborn’s fontanelles?

A nurse is performing the physical maturity test on a newborn using the New Ballard Scale. What characteristic would the nurse assess?

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A nurse is teaching a class on Apgar scoring to nursing students. Which statement by a student indicates a need for further teaching

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