The nurse talks to a patient who reports eye pain, nausea, vomiting, and halos around lights. Which is the most important action for the nurse to take?

Assess cranial nerve III (oculomotor)

Initiate emergency referral

Assess the corneal light reflex

Assess for presbyopia

Answer and Explanation

The Correct Answer is B

Acute angle-closure glaucoma is ophthalmic emergency due to sudden trabecular meshwork obstruction causing elevated intraocular pressure, optic nerve ischemia, presenting with severe ocular pain, nausea, vomiting, glaucoma, intraocular pressure, optic nerve, halos.

Rationale:

A. Cranial nerve III assessment evaluates ocular motor function involvement assessment. Cranial nerve III controls most extraocular eye movements functionally. Oculomotor dysfunction presents with ptosis diplopia not acute pain state. Symptoms here indicate intraocular pressure emergency not nerve palsy process.

B. Acute angle-closure glaucoma is ophthalmic emergency from sudden trabecular blockage causing high intraocular pressure. acute angle-closure presents with severe eye pain, halos, nausea. emergency referral is required to prevent vision loss. Delay results in optic nerve ischemia and blindness state.

C. Corneal light reflex assesses ocular alignment via cranial nerve II and III pathways. corneal reflex tests blink response to corneal stimulation touch. alignment abnormalities indicate strabismus not acute ocular pressure emergency. Symptoms require urgent referral not reflex testing process state.

D. Presbyopia is age-related loss of lens accommodation due to decreased elasticity causing near vision difficulty. presbyopia develops gradually after age 40 years. age-related changes do not cause eye pain or halos. Symptoms here indicate acute pathology not refractive aging state.

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

Inner ear pathology involves vestibular and labyrinth dysfunction causing vertigo, tinnitus, and sensorineural hearing loss due to endolymph imbalance, hair cell damage, or cranial nerve VIII injury processes present state

Rationale:

A. Cloudy yellow drainage indicates external ear canal infection present. This finding is typical of otitis externa bacterial inflammation. Inner ear disorders do not produce purulent ear discharge. Therefore symptom does not indicate vestibular system involvement clinically in inner ear disease process

B. Tragus tenderness suggests external ear canal inflammation present. This finding is associated with otitis externa infection. Inner ear pathology does not cause localized tragal pain. Pain results from external canal manipulation and inflammation response in bacterial otitis externa condition present state

C. Impacted cerumen obstructs external auditory canal sound conduction. This condition leads to conductive hearing loss mechanism due to sound transmission blockage in canal lumen. It does not produce vestibular symptoms such as dizziness. Inner ear structures remain unaffected in cerumen impaction cases

D. Tinnitus represents perception of sound without external stimulus. It commonly indicates sensorineural hearing loss or cochlear dysfunction. This symptom is strongly associated with vestibular labyrinth disorders. Inner ear damage affects cranial nerve VIII signaling pathways causing auditory processing disturbances present clinically relevant

A. Deviated nipple B. "peau d'organge" edema C. Cyclic tenderness D. Blood-tinged discharge

Correct Answer is C

Explanation

Breast Breast self-examination identifies suspicious breast pathology including malignancy indicators arising from ductal epithelial changes inflammatory invasion hormonal fluctuations lymphatic obstruction requiring systematic clinical correlation and diagnostic imaging follow-up evaluation assessment

Rationale:

A. Deviated nipple suggests underlying ductal distortion often associated with malignancy or fibrotic changes. This finding requires further diagnostic evaluation such as imaging. It is not benign. Therefore it does require follow-up and contradicts option stating no follow-up needed here

B. Peau d'orange edema reflects lymphatic obstruction from inflammatory breast carcinoma. Skin thickening and dimpling are serious red flags. This requires urgent oncologic assessment and imaging. It is not normal and always warrants follow-up evaluation immediately clinically required in care

C. Cyclic tenderness is hormonally mediated breast discomfort linked to luteal phase estrogen and progesterone fluctuations. It is benign bilateral predictable and resolves with menses. No diagnostic workup is required unless persistent or atypical symptoms occur clinically no follow-up needed here

D. Blood-tinged discharge is a concerning sign of possible intraductal carcinoma or papilloma. It requires immediate diagnostic evaluation including imaging and cytology. It is not physiologic and always warrants follow-up with healthcare provider for malignancy exclusion follow-up required clinically needed

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The nurse talks to a patient who reports eye pain, nausea, vomiting, and halos around lights. Which is the most important action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient who reports dizziness and hearing loss. Which finding would most likely indicate inner ear involvement?

Correct Answer is ["A","D","E"]

Explanation

The nurse teaches a patient to perform a breast self-exam (BSE). Which finding does NOT need a follow-up with the patients' health care provider?

Correct Answer is C

Explanation

The nurse counsels a female patient who has been diagnosed with a sexually transmitted infection (STI). Which interventions should the nurse promote? Select all that apply.

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The patient is standing 10 feet from the eye chart but can only read what a person with normal vision could see from 200 feet away. What does the nurse document about the patient's vision?

A nurse is assessing a patient suspected of having hyperthyroidism. Which of the following symptoms would support this diagnosis? (Select all that apply.)