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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:
This approach is recommended as it allows for a systematic comparison between the two sides of the chest. Percussion should start at the apices of the lungs, which are located just above the clavicles, and proceed downwards. This method ensures that any differences in percussion note, which could indicate underlying pathology, are identified by direct comparison.

Choice B Reason:
While this approach also involves a systematic assessment, it does not allow for immediate comparison between the two sides of the chest. It is important to compare corresponding areas on each side as you go to detect any asymmetry or changes in resonance.

Choice C Reason:
This method, similar to choice B, does not facilitate immediate side-to-side comparison during the assessment. Immediate comparison is crucial for identifying subtle differences that may indicate conditions such as pleural effusion or pneumothorax.

Choice D Reason:
Starting the percussion above the left clavicle and moving to the right chest after completing the left side does not allow for direct comparison of symmetrical chest areas. Additionally, assessing the right chest moving upward from the liver is not a standard practice, as the liver dullness can interfere with the percussion of the lower right lung fields.

A. Diabetes mellitus B. Liver disease C. End-stage renal disease D. Colon cancer

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?

Correct Answer is A

Explanation

In which disease process should a nurse expect to see a patient with the presence of pitting edema?

Correct Answer is B

Explanation

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