When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?
Down
To the left
To the right
Up
The Correct Answer is D
Choice A Reason:
Looking down does not typically expose the sclera and conjunctiva for examination. The lower eyelid covers more of the sclera when the eyes are directed downward, making it less accessible for observation.
Choice B Reason:
Moving the eyes to the left is not the standard direction for examining the sclera and conjunctiva. This movement would not provide an optimal view of the entire sclera and conjunctiva, as it would only stretch the lateral part of the conjunctiva.
Choice C Reason:
Directing the eyes to the right, similar to moving them to the left, does not offer the best exposure for examining the sclera and conjunctiva. The medial part of the conjunctiva would be stretched, but the rest would not be easily visible.
Choice D Reason:
Instructing the client to look up is the correct procedure when examining the sclera and conjunctiva. By looking upward, the client exposes more of the sclera and the palpebral conjunctiva, allowing the nurse to inspect these areas thoroughly for any abnormalities such as redness, swelling, or foreign bodies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The facial nerve, or cranial nerve VII, is responsible for the taste sensation in the anterior two-thirds of the tongue, not the posterior third. It carries taste sensations from the front part of the tongue via the chorda tympani branch.
Choice B Reason:
The abducens nerve, or cranial nerve VI, has no role in taste sensation. It is primarily involved in controlling the lateral rectus muscle of the eye, which abducts the eye.
Choice C Reason:
The glossopharyngeal nerve, or cranial nerve IX, provides special sensory innervation for taste to the posterior third of the tongue. This enables the sensation of various tastes like salty, sweet, sour, and bitter in this region.
Choice D Reason:
The hypoglossal nerve, or cranial nerve XII, is responsible for motor control of the tongue muscles but does not provide sensory innervation for taste.
Correct Answer is B
Explanation
Choice A reason:
Diabetes mellitus is not typically associated with pitting edema unless it has led to a comorbid condition such as heart failure or kidney disease. Pitting edema is more commonly associated with fluid retention due to the body's inability to manage fluid balance, which is not a direct consequence of diabetes mellitus itself.
Choice B reason:
Liver disease, particularly cirrhosis, can lead to pitting edema. The liver's inability to produce albumin, a protein that helps maintain oncotic pressure in the blood vessels, and portal hypertension, which is an increase in the blood pressure within the portal vein system, can both contribute to the development of pitting edema.
Choice C reason:
End-stage renal disease can also cause pitting edema due to the kidneys' inability to excrete excess fluid. However, the edema associated with renal disease is often more generalized and not limited to the lower extremities.
Choice D reason:
Colon cancer is not typically associated with pitting edema unless it has metastasized and caused secondary complications that affect the liver or the heart. Pitting edema is not a direct symptom of colon cancer itself. 
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