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 ["A","C","D"]
Explanation
Choice A Reason:
Assessing vital signs is crucial for evaluating the client's responses to treatment. Changes in vital signs can indicate whether the body is responding positively or negatively to a treatment, allowing healthcare providers to adjust care plans accordingly. For example, a decrease in fever after administering antipyretics would suggest the treatment is effective.
Choice B Reason:
While carrying out orders from the healthcare provider is a responsibility of the nurse, it is not the primary reason for assessing vital signs. Vital signs are assessed to inform clinical decisions, not solely to fulfill orders. Therefore, this choice is not correct in the context of the importance of vital sign assessment.
Choice C Reason:
Monitoring risks for alterations in health is another key reason for assessing vital signs. Vital signs can serve as early indicators of health issues, such as the onset of an infection indicated by a rising temperature or cardiovascular problems suggested by changes in blood pressure or heart rate.
Choice D Reason:
Establishing a baseline is essential when assessing vital signs. It provides a reference point for future comparisons, which is important for detecting any deviations from the client's normal range. This helps in identifying potential health issues early and monitoring the progression of known conditions.
Correct Answer is C
Explanation
Choice A Reason:
Palpitations are typically associated with hyperthyroidism, not hypothyroidism. They occur due to an excess of thyroid hormones, which can overstimulate the heart, leading to increased heart rate and palpitations. In hypothyroidism, the heart rate is usually slower, and palpitations are less common.
Choice B Reason:
Diaphoresis, or excessive sweating, is also more commonly associated with hyperthyroidism. In hypothyroidism, the metabolism is slowed down, which reduces the tendency for increased sweating. Patients with hypothyroidism may actually have less sweating than normal.
Choice C Reason:
Weight gain is a common symptom of hypothyroidism. Due to the decreased metabolic rate caused by low levels of thyroid hormones, the body burns fewer calories, which can lead to weight gain. This is one of the hallmark signs of hypothyroidism and is often one of the first symptoms patients notice.
Choice D Reason:
Exophthalmos, the protrusion of the eyes, is a symptom associated with Graves' disease, a form of hyperthyroidism. It is not a symptom of hypothyroidism. In hypothyroidism, any eye changes are usually related to puffiness or edema around the eyes, not the bulging of the eyes themselves.
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