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?
Purulent secretions from eyes and nares.
Snoring and bilateral, pale gray nodules.
Intranasal edema and swelling of turbinates.
Eye tearing and thick yellow nasal drainage.
The Correct Answer is C
Choice A Reason:
Purulent secretions from eyes and nares is incorrect. Purulent secretions, which are thick and yellow or green in color, typically indicate the presence of a bacterial infection rather than allergic rhinitis. Allergic rhinitis is more commonly associated with clear nasal discharge, although it can sometimes be accompanied by a mild increase in nasal secretions.
Choice B Reason:
Snoring and bilateral, pale gray nodules is incorrect. Snoring and bilateral, pale gray nodules suggest adenoid hypertrophy rather than allergic rhinitis. Adenoid hypertrophy refers to enlargement of the adenoids, which are lymphoid tissue located in the back of the nasal cavity. Enlarged adenoids can lead to snoring and the presence of grayish nodules upon examination of the nasopharynx.
Choice C Reason:
Intranasal edema and swelling of turbinates are correct. Intranasal edema (swelling inside the nose) and swelling of turbinates are characteristic features of allergic rhinitis. Allergic rhinitis results from inflammation of the nasal mucosa in response to exposure to allergens, leading to nasal congestion and swelling of the turbinates.
Choice D Reason:
Eye tearing and thick yellow nasal drainage is incorrect. Eye tearing and thick yellow nasal drainage suggest the presence of sinusitis rather than allergic rhinitis. Sinusitis is characterized by inflammation of the sinuses, which can result in symptoms such as facial pain or pressure, thick nasal discharge, and eye tearing due to sinus pressure affecting the tear ducts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Asking the client to recall what was consumed for lunch and breakfast is appropriate. Asking the client to recall recent events, such as what was consumed for lunch and breakfast, helps assess their short-term memory. Difficulty recalling recent events or recent medication doses may indicate emery impairment or cognitive decline, which could be contributing to the reported confusion and forgetfulness. This assessment provides valuable information about the client's ability to retain and recall recent information, which is pertinent to understanding the extent of memory impairment.
Choice B Reason:
Asking the spouse how often the pain medication is to be taken is inappropriate. While asking the spouse about the pain medication regimen provides information about the client's medication schedule, it does not directly assess the client's memory. Additionally, relying solely on the spouse's report may not accurately reflect the client's memory abilities or recall of medication instructions.
Choice C Reason:
Request for the spouse to write down the things the client forgets is inappropriate. Asking the spouse to write down forgotten items may help track memory lapses but does not directly assess the client's memory during the home visit. It also does not provide real-time information about the client's ability to recall recent events or medication instructions.
Choice D Reason:
Observing client ability to perform activities of daily living (ADLs) is inappropriate. Assessing the client's ability to perform activities of daily living (ADLs) is important for evaluating overall functional status but may not specifically target memory assessment. While memory impairment can impact ADL performance, it is not the most direct assessment for evaluating memory specifically during the home visit.
Correct Answer is A
Explanation
Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis).Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.
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