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?
Down
To the left
To the right
Up
The Correct Answer is D
Choice A Reason:
Looking down does not typically expose the sclera and conjunctiva for examination. The lower eyelid covers more of the sclera when the eyes are directed downward, making it less accessible for observation.
Choice B Reason:
Moving the eyes to the left is not the standard direction for examining the sclera and conjunctiva. This movement would not provide an optimal view of the entire sclera and conjunctiva, as it would only stretch the lateral part of the conjunctiva.
Choice C Reason:
Directing the eyes to the right, similar to moving them to the left, does not offer the best exposure for examining the sclera and conjunctiva. The medial part of the conjunctiva would be stretched, but the rest would not be easily visible.
Choice D Reason:
Instructing the client to look up is the correct procedure when examining the sclera and conjunctiva. By looking upward, the client exposes more of the sclera and the palpebral conjunctiva, allowing the nurse to inspect these areas thoroughly for any abnormalities such as redness, swelling, or foreign bodies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a reason:
Draping body areas that are not being assessed is important for maintaining the client's privacy and comfort, but it is not the highest priority when dealing with a client with generalized muscle weakness. The primary concern is to prevent further strain or injury during the examination.
Choice b reason:
Limiting position changes as much as possible is the priority when examining a client with generalized muscle weakness. Frequent or unnecessary movements can cause fatigue, discomfort, and may even be unsafe if the client has severely compromised muscle strength. The nurse should plan the examination to minimize the number of times the client needs to change positions.
Choice c reason:
Hand-washing throughout the exam is a standard practice to prevent the spread of infection. While it is crucial for both the client's and the nurse's safety, in the context of a client with generalized muscle weakness, the priority is to conduct the exam in a way that does not exacerbate the client's condition.
Choice d reason:
Using alcohol swabs to clean the stethoscope before and after the exam is also a standard infection control practice. However, it is not the most immediate concern when prioritizing the steps of a physical examination for a client with muscle weakness.
Correct Answer is C
Explanation
Choice A Reason:
The facial nerve, or cranial nerve VII, is responsible for the taste sensation in the anterior two-thirds of the tongue, not the posterior third. It carries taste sensations from the front part of the tongue via the chorda tympani branch.
Choice B Reason:
The abducens nerve, or cranial nerve VI, has no role in taste sensation. It is primarily involved in controlling the lateral rectus muscle of the eye, which abducts the eye.
Choice C Reason:
The glossopharyngeal nerve, or cranial nerve IX, provides special sensory innervation for taste to the posterior third of the tongue. This enables the sensation of various tastes like salty, sweet, sour, and bitter in this region.
Choice D Reason:
The hypoglossal nerve, or cranial nerve XII, is responsible for motor control of the tongue muscles but does not provide sensory innervation for taste.
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