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 B
Explanation
Choice A rationale
Turning the patient to the right side immediately after medication administration via a tube is generally not recommended as it may promote rapid gastric emptying which can potentially lead to dumping syndrome or alter drug absorption by moving the medication out of the stomach too quickly.
Choice B rationale
Leaving the patient in a high-Fowler's position for 30 minutes after administering medications through a tube helps prevent aspiration by utilizing gravity to keep the medication in the stomach. This position also aids in proper digestion and absorption by maintaining gastrointestinal motility and reducing reflux.
Choice C rationale
Flushing the tube with 10-15 mL of water after each medication is generally insufficient to clear the tube effectively and prevent clogging, especially with viscous medications. A standard flush volume of 30-60 mL is typically recommended to ensure complete medication delivery and tube patency.
Choice D rationale
Holding medication if 50 mL of residual is obtained is not a universal standard. The acceptable residual volume varies based on institutional policy, patient condition, and the type of feeding. Often, a residual volume of 200-250 mL or more is the threshold for holding medications.
Correct Answer is B
Explanation
Choice A rationale
Determining areas of tenderness is typically done through palpation, which should follow auscultation to avoid altering bowel sounds. Performing palpation first could elicit guarding or muscle rigidity, making subsequent auscultation less accurate and potentially increasing patient discomfort.
Choice B rationale
Auscultation precedes percussion and palpation of the abdomen to ensure that bowel sounds are not artificially stimulated or inhibited. Mechanical manipulation of the abdomen through percussion and palpation can alter the frequency and character of bowel sounds, leading to inaccurate assessment of intestinal motility.
Choice C rationale
While patient comfort is important, the primary reason for the sequence of abdominal assessment is scientific accuracy. Manipulating the abdomen prior to auscultation can stimulate peristalsis, creating false-positive bowel sounds or increasing existing ones, thus obscuring the true baseline activity.
Choice D rationale
Distortion of vascular sounds like bruits and hums is less likely to be significantly affected by percussion and palpation compared to bowel sounds. Vascular sounds originate from blood flow dynamics, which are not as readily influenced by external mechanical manipulation as the peristaltic activity of the intestines.
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