A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

Prolonged tonsillar enlargement

History of allergies

Incomplete immunization record

History of epistaxis nosebleeds

Answer and Explanation

The Correct Answer is B

Choice A reason: Prolonged tonsillar enlargement may cause throat issues or obstruction, but rhinorrhea stems from nasal inflammation, not tonsils. This focuses on oropharyngeal anatomy, missing the direct nasal etiology tied to runny nose in upper airway complaints here entirely.

Choice B reason: Allergies trigger nasal inflammation via histamine, causing rhinorrhea as IgE-mediated mast cells release mediators. A history of this is key, directly linking environmental triggers to the client’s runny nose, making it the most relevant assessment area accurately.

Choice C reason: Incomplete immunizations increase infection risk, but rhinorrhea more commonly ties to allergies or viruses than vaccine-preventable diseases here. This is less specific to the symptom’s etiology without fever or systemic signs, reducing its pertinence significantly.

Choice D reason: Epistaxis (nosebleeds) relates to vascular fragility, not mucus production like rhinorrhea. Past bleeding doesn’t explain runny nose, focusing on a separate nasal issue, making it less relevant to the upper airway complaint’s root cause in this case fully.

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Correct Answer is D

Explanation

Choice A reason: Macular degeneration impairs central vision, not pupil size. Pinpoint pupils and lethargy suggest systemic effects, not retinal aging, making this unrelated to the neurological and ocular findings in this emergency setting entirely and fully here.
Choice B reason: Eye trauma may dilate pupils from injury, not pinpoint them. Lethargy and change per the significant other point to systemic causes, not local trauma, excluding this as the likely explanation for this presentation comprehensively here.
Choice C reason: Bilateral cataracts cloud lenses, not affecting pupil size or alertness. Pinpoint pupils with lethargy suggest a neurological cause, not lens opacity, rendering this irrelevant to the acute change observed in this client fully here.
Choice D reason: Narcotic use, like opioids, causes pinpoint pupils via cranial nerve III stimulation and lethargy from CNS depression. This matches the sudden change and symptoms, making it the most likely interpretation in this emergency case accurately here.

A. "I am going to place my hand on your cheek, and I want you to turn your head against resistance." B. "I’m going to place my fingers in front of your ear, and I want you to open your mouth as wide as possible." C. "I want you to move your jaw from side to side and tell me if there is any pain with the movement." D. "Push out and pull in your lower jaw and let me know if you experience popping or grating."

Correct Answer is A

Explanation

Choice A reason: Turning the head against resistance assesses neck muscles, not the temporomandibular joint (TMJ), which hinges the jaw. TMJ evaluation requires jaw-specific movements, not cervical rotation, indicating a misunderstanding of TMJ anatomy and function, misaligning with headache assessment needs.

Choice B reason: Opening the mouth wide while fingers are placed near the ear directly tests TMJ range of motion and joint integrity. This is a standard technique to detect dysfunction or pain, correctly targeting the jaw’s articulation point relevant to headaches.

Choice C reason: Moving the jaw side to side evaluates TMJ lateral excursion, a key diagnostic motion. Pain reporting during this action helps identify joint issues tied to chronic headaches, making it an appropriate and precise instruction for TMJ assessment.

Choice D reason: Pushing out and pulling in the jaw tests TMJ protrusion and retraction, critical for assessing joint stability and sounds like popping, which may link to headache etiology. This instruction correctly focuses on TMJ mechanics and symptoms.

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A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

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Correct Answer is D

Explanation

A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

Correct Answer is A

Explanation

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