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 A

Explanation

a) The patient is unable to see in half of the visual field (same visual field) in each eye:

Homonymous hemianopsia is a condition where there is a loss of vision in the same side of the visual field in both eyes. This occurs due to damage to the visual pathways after the optic chiasm, often from a stroke or brain injury, resulting in the loss of either the right or left visual field in both eyes.

b) The patient can see from one eye but not through the other one:

This description fits a condition called monocular blindness, which is typically caused by damage to the optic nerve before it reaches the optic chiasm. Homonymous hemianopsia involves both eyes and specific visual fields, not complete loss of vision in one eye.

c) The patient is unable to see in half of the visual field (opposite visual field) in each eye:

This option describes bitemporal hemianopsia, which results in loss of vision in the outer (temporal) fields of both eyes and is often due to damage at the optic chiasm. Homonymous hemianopsia involves the same side of the visual field in both eyes, not the opposite visual fields.

d) No visual impairment:

Homonymous hemianopsia is characterized by significant visual impairment, specifically the loss of half the visual field in both eyes on the same side. Therefore, it is incorrect to say there is no visual impairment with this condition.

A. Inquire about family history of headaches. B. Review the client's medical record. C. Assess the client's blood pressure. D. Provide medication for pain relief.

Correct Answer is C

Explanation

(a) Inquire about family history of headaches:

While understanding the client's family history of headaches can be important for a comprehensive assessment, it is not the immediate priority. The description of "the worst headache" ever experienced could indicate a serious condition that needs urgent attention.

(b) Review the client's medical record:

Reviewing the client's medical record provides valuable information about their history and potential underlying conditions. However, given the severity of the reported headache, it is crucial to perform a more immediate physical assessment to rule out life-threatening conditions.

Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.

(d) Provide medication for pain relief:

Providing pain relief is important, but it should not be the first action without determining the cause of the headache. Administering medication without assessing the client's condition could mask symptoms of a potentially serious underlying issue such as a stroke or hypertensive emergency.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is diagnosed with Homonymous Hemianopsia. The nurse expects to find what defects in the visual field of this patient:

Correct Answer is A

Explanation

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?

Correct Answer is C

Explanation

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