Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Inspection.

Auscultation.

Palpation.

Percussion.

Answer and Explanation

The Correct Answer is A

A. Inspection. Papilledema, swelling of the optic disc due to increased intracranial pressure, is primarily assessed through inspection of the optic disc using an ophthalmoscope. The nurse would look for optic disc swelling and blurred disc margins.

B. Auscultation. Auscultation is not appropriate for assessing papilledema, as it involves listening for sounds such as heart, lung, or bowel sounds.

C. Palpation. Palpation is not appropriate for assessing papilledema, as it involves touching and feeling for abnormalities, which would not be possible with the optic disc.

D. Percussion. Percussion is not appropriate for assessing papilledema, as it involves tapping the body surface to elicit sounds or vibrations, which would not provide information about the optic disc.

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Correct Answer is B

Explanation

A. Detailed questions about a symptom: This technique is beneficial for gathering specific information about a symptom. However, asking detailed questions right from the start may not allow the client to provide a broad overview of their symptoms and could limit the information shared.

B. Open-ended questioning: Open-ended questions encourage the client to describe their symptoms in their own words, providing a comprehensive and detailed account. This approach is particularly useful in understanding the quality, color, and consistency of the sputum, which are important details in the assessment of pneumonia. This technique allows for a thorough and unbiased description of the sputum, which is crucial for a complete health assessment in the context of bilateral pneumonia.

C. Leading questions: Leading questions suggest a particular answer and can bias the client's response. For example, asking "Is your sputum thick and green?" may lead the client to agree even if their sputum is different, thus providing inaccurate information.

D. Closed-ended questions: Closed-ended questions elicit short, often one-word answers, such as "yes" or "no." While these can be useful for clarifying specific details, they do not provide the comprehensive description needed to assess the sputum thoroughly in the context of pneumonia.

A. Inspection of the abdomen for enlargement, B. Palpation of an abdominal fluid wave. C. Bimanual palpation for liver enlargement. D. Successive measurements of abdominal girth.

Correct Answer is B

Explanation

A. Inspection of the abdomen for enlargement: Ascites causes abdominal distention. Inspection is a straightforward way to assess for fluid accumulation.

B. Palpation of an abdominal fluid wave: Palpating for a fluid wave (shifting of fluid within the abdomen) is a classic sign of ascites.

C. Bimanual palpation for liver enlargement: While liver enlargement can contribute to ascites, it is not the primary method for detecting early ascites.

D. Successive measurements of abdominal girth: Regular measurements of abdominal girth help track changes over time and detect early ascites.

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Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

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Naxlex Comprehensive Predictor Exams

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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