A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Intranasal edema and swelling of turbinates.

Eye tearing and thick yellow nasal drainage.

Purulent secretions from eyes and nares.

Snoring and bilateral, pale gray nodules.

Answer and Explanation

The Correct Answer is A

A) Intranasal edema and swelling of turbinates:
Allergic rhinitis is characterized by inflammation of the nasal mucosa in response to allergen exposure. This inflammation leads to symptoms such as nasal congestion, sneezing, and rhinorrhea. Intranasal edema and swelling of the turbinates are common findings in allergic rhinitis due to the body's immune response to allergens.

B) Eye tearing and thick yellow nasal drainage:
Eye tearing and thick yellow nasal drainage are more indicative of a bacterial infection rather than allergic rhinitis. In allergic rhinitis, nasal discharge is typically clear and watery.

C) Purulent secretions from eyes and nares:
Purulent secretions from the eyes and nares suggest a bacterial infection rather than allergic rhinitis. Allergic rhinitis typically presents with clear nasal discharge, while purulent secretions are more commonly associated with bacterial sinusitis or conjunctivitis.

D) Snoring and bilateral, pale gray nodules:
Snoring and bilateral, pale gray nodules are not characteristic findings of allergic rhinitis. Snoring may be associated with nasal congestion, but pale gray nodules are not typically observed in allergic rhinitis. These findings may indicate other nasal or upper airway conditions such as nasal polyps or adenoid hypertrophy.

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Correct Answer is C

Explanation

A) Looking at the client from the side, observe the size and shape of the chest wall:
This action is more related to inspecting the physical appearance and symmetry of the chest wall but does not assess tactile fremitus.

B) Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation:
This action may be more relevant for assessing subcutaneous emphysema (crepitus) but is not the correct method for assessing tactile fremitus.

C) Place the palm of the hand on the chest wall to feel vibrations while the client speaks:
This is the correct action to assess tactile fremitus. By placing the palm of the hand on various areas of the chest wall while the client repeats a phrase such as "ninety-nine," the nurse can feel for vibrations. Increased tactile fremitus can indicate consolidation, as seen in pneumonia.

D) Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly:
This action involves auscultation, which is important for assessing breath sounds but does not assess tactile fremitus directly.

A. Neurological status intact. B. Glasgow Coma Scale (GCS) of 15. C. Pupils equal, round, reacts to light, and accommodation (PERLA). D. Pupils equal, round, reacts to light (PERRL).

Correct Answer is D

Explanation

A) Neurological status intact: While the findings suggest that the client's neurological status is intact, this description does not specifically address the pupillary assessment.

B) Glasgow Coma Scale (GCS) of 15: The Glasgow Coma Scale evaluates a client's level of consciousness based on eye, verbal, and motor responses. While the findings may contribute to an overall assessment of neurological function, they specifically pertain to pupillary assessment.

C) Pupils equal, round, reacts to light, and accommodation (PERLA): This description includes accommodation, which is the ability of the pupils to constrict when focusing on a near object. The assessment provided in the scenario does not mention accommodation testing, so including it in the documentation would be inaccurate.

D) Pupils equal, round, reacts to light (PERRL): This notation accurately summarizes the findings of the pupillary assessment. It indicates that both pupils are equal in size, round in shape, and react briskly to light, which is a normal finding. This documentation is concise and specific to the pupillary examination without including additional findings not assessed in the scenario.

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A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is C

Explanation

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

Correct Answer is D

Explanation

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