A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?

Assess the nasolacrimal sac

Test pupillary reaction to light

Inspect the palpebral conjunctiva

Perform the eye positions test

Answer and Explanation

The Correct Answer is A

A) Assess the nasolacrimal sac: Excessive tearing, or epiphora, can result from an obstruction in the nasolacrimal duct, which drains tears from the eye into the nasal cavity. By assessing the nasolacrimal sac, the nurse can determine if there is any blockage or infection causing the excessive tearing, making this the most appropriate next step.

B) Test pupillary reaction to light: While testing pupillary reaction to light is important in a comprehensive eye exam, it does not directly address the issue of excessive tearing. This test is more focused on evaluating neurological function and overall eye health.

C) Inspect the palpebral conjunctiva: Inspecting the palpebral conjunctiva can help identify inflammation, infection, or foreign bodies that may cause discomfort or tearing. However, it does not specifically address the cause of excessive tearing related to nasolacrimal duct obstruction.

D) Perform the eye positions test: The eye positions test assesses extraocular muscle function and cranial nerve integrity. While it is important for a complete eye examination, it is not directly related to the symptom of excessive tearing, which is more likely due to issues with tear drainage.

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Correct Answer is C

Explanation

A) At the angle of the mandible:

Lymph nodes located at the angle of the mandible are the submandibular lymph nodes, not the occipital lymph nodes. These nodes are situated below the jawline and are assessed when looking for infections or abnormalities in the oral cavity and throat.

B) Temporal area:

The temporal area is not a typical location for lymph node palpation. This region is primarily related to the temporal artery and muscles, not to lymph nodes. Thus, palpating for lymph nodes here would not be relevant.

C) The posterior base of the skull:

The occipital lymph nodes are located at the posterior base of the skull, near the nape of the neck. These nodes drain the scalp and are assessed when there are scalp infections or other related conditions.

D) Area in front of the ears:

The lymph nodes in front of the ears are the preauricular lymph nodes. These nodes drain the eyes and the surrounding skin. They are not the occipital lymph nodes, which are situated at the back of the head.

A. Concussions in sports and motor vehicle accidents cause the largest number of TBIS in teens. B. Females have twice the risk that males do. C. Falls occur more frequently in the younger population. D. Most firearm incidents are accidental.

Correct Answer is A

Explanation

A) Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens: Adolescents are particularly susceptible to TBIs due to their frequent involvement in contact sports like football, soccer, and hockey, as well as risky behaviors associated with driving. These activities are leading causes of TBIs in this age group, making education on safety measures and proper use of protective equipment essential in prevention efforts.

B) Females have twice the risk that males do: This statement is incorrect. In reality, males are more likely to sustain TBIs than females, especially in adolescence. The higher risk in males is largely due to their greater participation in high-impact sports and higher likelihood of being involved in motor vehicle accidents.

C) Falls occur more frequently in the younger population: Although falls are a significant cause of TBIs in young children and older adults, they are not the primary cause in adolescents. Teens are more likely to sustain TBIs from sports injuries and car accidents, making these areas more relevant for preventive education.

D) Most firearm incidents are accidental: While firearm-related TBIs can occur, they are not as common in the adolescent population compared to injuries from sports and motor vehicle accidents. Prevention efforts should focus more on the activities that pose the highest risk for this age group.

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A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?

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