Which of the following would a nurse expect to assess in a client with esotropia?
Eye turning inward
Eye malalignment
Eye oscillating
Eye turning outward
The Correct Answer is A
A) Eye turning inward:
Esotropia is a condition where one or both eyes turn inward, leading to misalignment. This inward turning can cause double vision, depth perception issues, and sometimes amblyopia (lazy eye) if not treated early. This is the primary characteristic that defines esotropia.
B) Eye malalignment:
While eye malalignment is a general term that can describe conditions like esotropia, exotropia, or hypertropia, it does not specify the direction of the misalignment. Esotropia specifically refers to inward turning of the eye, which is a more precise description of the condition.
C) Eye oscillating:
Eye oscillation refers to nystagmus, which is a condition characterized by repetitive, uncontrolled movements of the eyes, often resulting in reduced vision. Nystagmus is not related to esotropia, which involves inward turning rather than oscillation.
D) Eye turning outward:
Eye turning outward is known as exotropia, which is the opposite of esotropia. Exotropia involves the eyes turning away from the nose, whereas esotropia involves the eyes turning towards the nose. These are distinct conditions with different clinical presentations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
(a) Liver Disease:
Pitting edema is commonly seen in liver disease, especially in conditions like cirrhosis. Liver disease can lead to hypoalbuminemia, where low levels of albumin in the blood cause fluid to leak into the interstitial spaces, resulting in edema. Additionally, liver disease often leads to portal hypertension, which can also contribute to the development of edema.
(b) Diabetes mellitus:
While diabetes can cause complications such as diabetic nephropathy, which may lead to fluid retention, pitting edema is not a primary symptom directly associated with diabetes mellitus. Diabetic patients may develop edema due to kidney issues, but it is not as directly associated as with liver disease.
(c) End Stage Renal Disease:
End-stage renal disease (ESRD) can indeed cause significant fluid retention and edema, including pitting edema. The kidneys' inability to excrete excess fluid leads to its accumulation in tissues. However, the question seems to point towards liver disease, which directly leads to conditions causing pitting edema.
(d) Colon Cancer:
Colon cancer is not typically associated with pitting edema. While advanced cancer can lead to various complications, including fluid imbalances, it is not a primary cause of pitting edema. Edema related to cancer is often more localized and associated with tumor sites or treatment areas.
Correct Answer is C
Explanation
A) Intercostal spaces:
Assessing intercostal spaces typically involves palpating or inspecting the area between the ribs to check for abnormalities such as retractions or tenderness, usually conducted with the client sitting or standing.
B) Lymph nodes:
Palpation of lymph nodes, such as in the cervical region, involves using fingertips to gently feel for enlarged or tender nodes. This examination focuses on areas like the neck, underarms, and groin.
C) Skin Turgor:
The image depicts a nurse pinching the skin, likely on the chest or forearm, which is a common method to assess skin turgor. Skin turgor evaluation helps determine hydration status; if the skin remains tented and returns slowly to its original position, it indicates dehydration.
D) Carotid Pulse:
Assessing the carotid pulse involves palpating the carotid artery along the side of the neck to evaluate the strength and rhythm of the pulse. This is typically done using the pads of the fingers, not by pinching the skin.
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