The nurse is palpating the sinus areas.
If the findings are normal, then the patient should report which sensation?
Pain sensation behind the eyes.
Pain during palpation.
Pressure but no pain or tenderness.
Tingling along the nose & eyes.
The Correct Answer is C
Choice A rationale
Pain sensation behind the eyes, particularly during palpation of the frontal or ethmoid sinuses, suggests inflammation or infection within these sinuses. Under normal conditions, healthy paranasal sinuses are air-filled cavities and should not elicit pain upon palpation.
Choice B rationale
Pain during palpation of any sinus area is indicative of sinusitis or inflammation. The presence of pain signifies pressure buildup, mucosal edema, or infection within the sinus cavities. Normal findings would not involve pain, but rather a sensation of mild pressure.
Choice C rationale
Normal findings during sinus palpation should elicit a sensation of pressure but no pain or tenderness. This indicates that the sinuses are air-filled, patent, and free from inflammation or congestion. The pressure is a result of the gentle digital compression over the bony structures.
Choice D rationale
Tingling along the nose and eyes is not a typical sensation associated with normal sinus palpation. This sensation might suggest neurological irritation, such as nerve compression or neuropathy, rather than a direct physiological response from the paranasal sinuses themselves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Directly placing pills in a client's mouth with a gloved hand is generally not recommended as it can be perceived as invasive and may trigger the gag reflex, increasing the risk of aspiration. Client autonomy and active participation in medication administration are promoted for safety and adherence.
Choice B rationale
Tipping pills directly into a client's mouth can be problematic as it does not allow the client to assess the medication, potentially leading to discomfort or aspiration. It also bypasses the client's agency in the medication administration process, which is crucial for safety and compliance.
Choice C rationale
Offering the client the medication in their hand promotes autonomy and allows them to actively participate in the medication administration process. This approach respects client preferences, enhances safety by allowing self-administration, and facilitates the client's ability to examine the medication before ingestion, reducing the risk of errors.
Choice D rationale
Leaving medications unattended on a breakfast tray for later self-administration is a significant safety breach. This practice increases the risk of the medication being taken by another individual, loss or contamination, or incorrect timing of administration, potentially leading to adverse drug events. Direct observation of medication ingestion is essential.
Correct Answer is A
Explanation
Choice A rationale
Tolerance is a physiological adaptation to a drug, characterized by a decreased response to the same dose, or a need for increased doses to achieve the same effect. In this case, the increased dosage of morphine over several weeks indicates that the client's body has adapted to the drug's effects, requiring more to manage pain.
Choice B rationale
An adverse reaction is an undesirable and unintended effect of a drug, occurring at normal doses. While an increased dosage might lead to adverse effects, the described scenario specifically highlights the need for a higher dose to maintain efficacy, which is characteristic of tolerance, not simply an adverse reaction.
Choice C rationale
Idiosyncrasy refers to an unpredictable, uncharacteristic, or exaggerated response to a drug that is not an allergic reaction. It is typically a genetically determined abnormal response that occurs with initial exposure or after a few doses, unlike tolerance which develops over time with repeated exposure.
Choice D rationale
Polypharmacy refers to the concurrent use of multiple medications by a patient, often more than medically necessary. While the client is receiving medication, the scenario specifically describes a change in dosage of a single medication due to a diminished response, which is characteristic of tolerance, not polypharmacy.
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