During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

Angular cheilitis

Herpes simplex

Angioedema

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Angular cheilitis is characterized by inflammation of one or both corners of the mouth. It often presents as red, swollen patches in the corners of the mouth and can be associated with fungal or bacterial infection. However, it does not typically cause vesicular eruptions, which are more indicative of viral infections like herpes simplex.

Choice B Reason:
Herpes simplex virus (HSV) is known for causing vesicular eruptions, commonly referred to as cold sores or fever blisters, around the lips and mouth area. These eruptions are fluid-filled blisters that can be painful and are highly indicative of an HSV infection, particularly HSV type 1, which commonly affects the oral region.

Choice C Reason:
Angioedema involves the rapid swelling of the deeper layers of the skin, often seen with hives. While it can affect the lips and surrounding areas, it does not cause vesicular eruptions. Angioedema is more associated with allergic reactions and can be part of anaphylaxis, a severe systemic reaction.

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Correct Answer is B

Explanation

Choice A reason:
Facial expression is an important aspect of the general survey as it can provide clues about a patient's emotional state and possible pain. However, it is not directly related to the patient's level of consciousness. After a motor vehicle crash, assessing facial expression is crucial to identify any signs of distress, trauma, or neurological impairment.
Choice B reason:
Level of consciousness is a critical component of the general survey, especially in the context of trauma or potential neurological injury. It refers to the patient's awareness and responsiveness to the environment. Assessing the level of consciousness involves determining if the patient is awake, alert, and oriented to time, place, and person, which is essential for establishing a baseline cognitive function and detecting any changes that may indicate deterioration or improvement in their condition.
Choice C reason:
Posture, gait, motor activity, and speech are assessed to evaluate the musculoskeletal and neurological systems. While these are important in the context of a motor vehicle crash, they are not specifically related to the level of consciousness. These assessments help identify any deficits that may result from injuries sustained during the crash, such as fractures, dislocations, or neurological damage affecting movement and coordination.
Choice D reason:
The apparent state of health is a broad assessment that includes the patient's overall appearance and any signs that may indicate acute or chronic illness. In the emergency setting, this may involve observing for signs of trauma, shock, or other life-threatening conditions. While it is an essential part of the general survey, it is not specifically focused on the level of consciousness but rather on the patient's general well-being and any obvious health concerns.

A. Assess the nasolacrimal sac B. Inspect the palpebral conjunctiva C. Test pupillary reaction to light D. Perform the eye positions test

Correct Answer is A

Explanation

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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During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to completing the physical examination of a patient post motor vehicle crash, the ER nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

Correct Answer is B

Explanation

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

Correct Answer is A

Explanation

During a comprehensive health history, a client reports coming into the hospital because he "feels like an elephant is sitting on his chest." The nurse will document this information in which of the following sections?

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?

The nurse working in the eye doctor's office is completing an assessment on an elderly client. Which of the following would a nurse expect to assess in a client with esotropia?

What cranial nerve is responsible for the taste sensation of the posterior third of the tongue?

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

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