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 B

Explanation

(a) Soles of the feet:

The soles of the feet are not considered the most reliable indicator of central cyanosis because peripheral areas can be affected by various factors, including temperature and circulation. Changes in color here might not accurately reflect central oxygenation status.

(b) Oral mucosa:

The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation status of the central circulatory system. Cyanosis in this area indicates a significant drop in arterial oxygen saturation and is a more direct indicator of hypoxemia compared to peripheral sites.

Ear lobes, like the soles of the feet, can be influenced by peripheral circulation and environmental factors. While cyanosis can be observed here, it is not as reliable as central sites like the oral mucosa for assessing systemic oxygenation.

(d) Conjunctivae:

The conjunctivae can show signs of cyanosis, but the oral mucosa is still a more sensitive and reliable indicator for central cyanosis. The oral mucosa provides a clear and consistent site to assess oxygenation in emergency situations.

A. Nail Beds B. Sclera C. Oral Mucosa D. Palms

Correct Answer is C

Explanation

A. Nail Beds:

While peripheral cyanosis can cause bluish discoloration of the nail beds, central cyanosis is more indicative of systemic hypoxemia and is best assessed in areas with rich blood supply, such as the oral mucosa.

B. Sclera:

The sclera is more commonly used to assess for jaundice (yellowing) rather than cyanosis. Cyanosis is not typically visible in the sclera.

C. Oral Mucosa:

Central cyanosis is most accurately assessed in areas with high vascularization, such as the oral mucosa. This area provides a clear indication of oxygenation status and can reveal hypoxemia more reliably than peripheral sites.

D. Palms:

Similar to the nail beds, the palms can show signs of peripheral cyanosis but are not the primary site for assessing central cyanosis. The oral mucosa remains the best site for this assessment.

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

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Naxlex Comprehensive Predictor Exams

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