The nurse reassesses a client who reports eye discomfort. Which client statement should prompt immediate concern?
"My eyes have been feeling dry and itchy, especially in the morning."
"I've noticed a few floaters and a sudden blind spot in my vision."
"My eyes feel discomfort after using my contact lenses all day."
"I have been getting mild headaches when I read for long periods."
The Correct Answer is B
A. "My eyes have been feeling dry and itchy, especially in the morning" reflects dry eye syndrome or allergic conjunctivitis. These conditions are generally chronic and manageable with interventions such as artificial tears or allergy medications and do not pose an immediate threat to vision.
B. "I've noticed a few floaters and a sudden blind spot in my vision" indicates a potential retinal tear or retinal detachment, which is an ophthalmic emergency. Sudden floaters, flashes of light, or blind spots suggest the retina may be tearing or detaching. If not treated urgently, this can lead to permanent vision loss. Immediate ophthalmologic evaluation and possible surgical intervention are required, making this statement the priority concern.
C. "My eyes feel discomfort after using my contact lenses all day" usually reflects minor irritation, dryness, or corneal abrasions caused by prolonged contact lens wear. While it needs attention, it is not immediately vision-threatening and can typically be managed by adjusting lens use or providing lubricating drops.
D. "I have been getting mild headaches when I read for long periods" is most likely caused by eye strain, uncorrected refractive errors, or poor lighting. This condition is non-urgent and does not indicate acute ocular pathology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An older adult with fragile skin and a new dark red bruise is of greatest concern. Older adults often have thinner, more fragile skin due to aging, making them more susceptible to skin tears, bruising, and pressure injuries. A new dark red bruise may indicate trauma, potential falls, or even elder abuse, which requires immediate assessment and follow-up. Monitoring for hematomas, skin integrity, and underlying causes is critical.
B. A child with fine vellus hair and no signs of rash represents a normal skin finding in children. Fine, soft vellus hair is expected, and without any rashes, lesions, or other abnormalities, there is no immediate concern.
C. A pregnant client with increased sweating and mild skin darkening is experiencing normal physiological changes of pregnancy, such as hyperpigmentation (linea nigra, melasma) and increased diaphoresis. These are typically benign and do not indicate urgent pathology.
D. An adolescent with mild acne and oily skin is experiencing common hormonal skin changes of puberty. While acne management may be appropriate, it is not an immediate concern for acute skin compromise or systemic issues.
Correct Answer is B
Explanation
A. Pulling the pinna forward and up does not effectively straighten the adult ear canal. The external auditory canal in adults has a natural upward and forward curve, so pulling forward does not properly align the canal for visualization of the tympanic membrane.
B. In adults (and children older than 3 years), the nurse should pull the pinna up and back when inserting the otoscope. This maneuver straightens the S-shaped external auditory canal, allowing clear visualization of the tympanic membrane. Proper positioning reduces discomfort and prevents injury during the examination.
C. Pulling the pinna down and back is appropriate for infants and young children under 3 years of age. In this age group, the ear canal is shorter and more horizontal. Using this technique on an adult would not properly align the canal.
D. Leaving the pinna in its natural position does not straighten the ear canal, making visualization of the tympanic membrane more difficult and potentially uncomfortable for the client.
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