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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Multiple yellow lesions with a grainy surface. These could indicate xanthomas, which are associated with lipid disorders and may warrant further investigation and treatment.
B. Large, flat, dark red irregular area on the neck. This could be a port-wine stain, which is typically a congenital condition and may not require immediate medical intervention unless associated with other symptoms.
C. Bluish discoloration of the nail beds. This indicates cyanosis, which can be a sign of hypoxia or cardiovascular issues. It requires prompt evaluation by a healthcare provider to determine the underlying cause and necessary interventions.
D. Multiple silver striae on the abdomen. Striae, or stretch marks, are usually benign and often result from rapid weight changes or hormonal variations. They typically do not require immediate medical attention.
Correct Answer is A
Explanation
A. Decreased height: Osteoporosis often leads to vertebral fractures, especially in the upper (thoracic) spine. These fractures can cause pain, height loss, and a stooped or hunched posture (kyphosis).
B. Loss of appetite: While osteoporosis itself does not directly cause loss of appetite, it’s essential to assess overall health and nutritional status. However, this symptom is not directly related to kyphosis.
C. Weight gain: Weight gain is not typically associated with osteoporosis or kyphosis. It is less relevant in this context.
D. Painful swallowing: Painful swallowing is not directly related to osteoporosis or kyphosis. It is less relevant in this context.
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