A nurse is preparing to assess a client’s conjunctiva.
Identify the sequence the nurse should follow when taking the following actions.
1) Apply examination gloves.
2) Instruct the client to look up.
3) Place the thumbs below each of the client’s lower eyelids.
4) Gently pull the client’s skin down to the top edge of the bony orbital rim.
5) Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions.
1, 2, 3, 4, 5
2, 1, 4, 3, 5
1, 4, 2, 3, 5
2, 3, 1, 4, 5.
The Correct Answer is A
The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva. This is because the nurse should first apply examination gloves to prevent contamination and infection. Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva. Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim. This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions. The sclera should be white and the conjunctiva should be pink.
Choice B is wrong because the nurse should not pull down the skin before instructing the client to look up.
This could cause discomfort and injury to the eye.
Choice C is wrong because the nurse should not instruct the client to look up after pulling down the skin.
This could also cause discomfort and injury to the eye.
Choice D is wrong because the nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.
This could introduce infection and irritants to the eye.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Thin and transparent skin is a sign of prematurity in newborns.The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics.
The other choices are signs of maturity or postmaturity in newborns:
• Choice B: Well-developed breastbuds indicate a gestational age of 38 to 44 weeks.
• Choice C: Creases on the bottom of feet indicate a gestational age of 32 to 44 weeks.
• Choice D: Developed labia indicate a gestational age of 40 to 44 weeks.
The normal range for gestational age is 37 to 42 weeks.Premature infants are those born before 37 weeks, and postmature infants are those born after 42 weeks.
Correct Answer is B
Explanation
Bulging fontanelles.Bulging fontanelles can be a sign of increased intracranial pressure or intracranial and extracranial tumors.This is a potential problem for the newborn’s brain and health and should be evaluated by imaging studies.
Choice A is wrong because sunken fontanelles are usually a sign of dehydration, which is not a problem with the fontanelles themselves, but with the fluid balance of the newborn.
Choice C is wrong because a diamond-shaped anterior fontanelle is normal for a newborn.The anterior fontanelle is the largest and most important for clinical evaluation.It has an average size of 2.1 cm and a median time of closure of 13.8 months.
Choice D is wrong because a triangular posterior fontanelle is also normal for a newborn.The posterior fontanelle is smaller than the anterior one and normally closes by 8 weeks.
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