The nurse working in the eye doctor's office is completing an assessment on an elderly client. Which of the following would a nurse expect to assess in a client with esotropia?
Eye malalignment
Eye turning outward
Eye oscillating
Eye turning inward
The Correct Answer is D
Choice a reason:
Eye malalignment is a general term that refers to any form of misalignment of the eyes, which can include esotropia but is not specific to it. Esotropia is a type of strabismus where there is a specific pattern of eye malalignment.
Choice b reason:
Eye turning outward is known as exotropia, which is the opposite of esotropia. In exotropia, one or both eyes turn outward away from the nose, which is not characteristic of esotropia.
Choice c reason:
Eye oscillating refers to nystagmus, a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception. While nystagmus can occur in conjunction with esotropia, it is not a defining characteristic of esotropia itself.
Choice d reason:
Eye turning inward is the hallmark of esotropia. In this condition, one or both eyes turn inward towards the nose. It can be constant or intermittent and may affect one eye or alternate between both eyes. Esotropia can be comitant, meaning the degree of deviation is the same in every direction of gaze, or incomitant, where the deviation varies with gaze direction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Vertigo is a common complication associated with inner ear infections, such as labyrinthitis or vestibular neuritis. The inner ear is responsible for balance, and when it is infected, it can lead to a sensation of spinning or dizziness. Interventions may include medications like meclizine or dimenhydrinate to alleviate symptoms, as well as safety measures to prevent falls.
Choice B Reason:
Rhinorrhea, or a runny nose, is not typically a direct complication of an inner ear infection. It may be associated with upper respiratory infections that can precede or accompany an ear infection but is not a result of the inner ear infection itself.
Choice C Reason:
Fever may be present if the inner ear infection is part of a systemic infection, such as the flu or bacterial meningitis. However, fever is not a direct result of an isolated inner ear infection. If fever is present, the nurse should monitor the patient's temperature and may administer antipyretics as ordered.
Choice D Reason:
Headache can be a symptom experienced by individuals with inner ear infections due to the general discomfort and pressure changes in the ear. However, it is not as specific or as common as vertigo when it comes to inner ear infections. If headaches are present, pain management strategies can be included in the care plan.
Correct Answer is C
Explanation
Choice a reason:
A penlight is used to provide illumination during an examination, not to move the tongue. It helps the nurse to visualize the mouth floor and other areas by casting light, but it does not have the physical structure to manipulate the tongue.
Choice b reason:
Gloves are worn by healthcare professionals to maintain hygiene and protect both the patient and the nurse from the transmission of infectious agents. They are not used to move the tongue to one side during an examination.
Choice c reason:
A gauze pad is the correct tool to use when the nurse needs to move the tongue to one side during an examination of the mouth floor. The nurse can wrap the gauze pad around the tongue for a better grip, which allows for safe and effective retraction of the tongue without causing discomfort to the patient.
Choice d reason:
A tongue blade, also known as a tongue depressor, is typically used to depress the tongue to examine the back of the throat, not to move the tongue to one side. It is used to hold the tongue down so that the nurse can inspect the oropharynx and other structures.
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