A nurse is assessing a patient with a complaint of cold and sinus pain. Which sinuses would the nurse palpate?
ethmoid
maxillary
mastoid
sphenoid
The Correct Answer is B
A. Ethmoid: The ethmoid sinuses are located between the eyes and are not typically accessible for palpation during a physical examination. Instead, tenderness in this area is assessed through inspection and indirect methods rather than direct palpation.
B. Maxillary: The maxillary sinuses are located in the cheeks and are accessible for palpation. The nurse can assess for tenderness or swelling in this area, which can indicate sinusitis or infection. Palpating the maxillary sinuses is a standard part of the examination for patients with cold and sinus pain.
C. Mastoid: The mastoid process is located behind the ear and contains air cells, but it is not directly involved in sinus pain associated with cold symptoms. While mastoid tenderness may indicate a different type of infection (such as mastoiditis), it is not part of the sinus assessment.
D. Sphenoid: The sphenoid sinuses are located deep within the skull, behind the nasal cavity, and are not accessible for palpation during a physical examination. Any issues with the sphenoid sinuses would typically be assessed through imaging studies rather than physical palpation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maxillary sinusitis: The symptoms described, including facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and dull, throbbing pain in the cheeks and teeth, are consistent with maxillary sinusitis. The maxillary sinuses are located in the cheeks, and inflammation or infection in this area can lead to referred pain in the teeth and facial areas. Tenderness upon palpation of the maxillary sinus area further supports this diagnosis.
B. Posterior epistaxis: Posterior epistaxis refers to bleeding from the back of the nasal cavity. While it can be associated with nasal pain, it does not typically present with fever, malaise, purulent discharge, or sinus-related pain.
C. Frontal sinusitis: Frontal sinusitis involves inflammation of the frontal sinuses located above the eyes, which may cause pain in the forehead and around the eyes. The patient's complaint of cheek and teeth pain is more indicative of maxillary sinusitis rather than frontal sinusitis.
D. Nasal polyps: Nasal polyps are non-cancerous growths that can occur in the nasal passages or sinuses, often leading to obstruction and difficulty breathing. While they can be associated with sinusitis, the acute presentation of fever, malaise, and purulent discharge, along with facial pain, is more indicative of an active infection, such as maxillary sinusitis.
Correct Answer is A
Explanation
A. Pericardial sac: The pericardial sac, also known as the pericardium, is a double-walled sac that surrounds and protects the heart. It consists of an outer fibrous layer and an inner serous layer, which produces pericardial fluid to reduce friction between the heart and surrounding structures during heartbeats. This structure provides support and helps maintain the position of the heart within the thorax.
B. Endocardial sac: The endocardium is the innermost layer of the heart wall that lines the heart chambers and covers the heart valves. It does not refer to a protective sac surrounding the heart.
C. Pleural sac: The pleural sac consists of two layers (visceral and parietal pleura) that encase the lungs and provide a lubricated surface for lung expansion and contraction during respiration. It is not related to the heart.
D. Myocardial sac: The myocardium refers to the muscular middle layer of the heart wall responsible for contraction and pumping blood. It is not a sac and does not surround or protect the heart.
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