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. Determine the client's most recent hemoglobin level: While low hemoglobin can be associated with conditions that cause clubbing, it's not the initial step. Documenting the finding is more important first.

B. Document the presence of nail bed clubbing: An angle of 200 degrees between the nail and nail bed is a classic sign of clubbing, which can be associated with various underlying conditions.

C. Administer a PRN prescription for oxygen: This is not indicated unless the client has respiratory problems, and clubbing itself doesn't necessitate oxygen.

D. Consult with a podiatrist: Consulting a podiatrist might be necessary for nail care in some situations, but it's not the most urgent action for nail bed clubbing. Documenting the finding and investigating the underlying cause is the priority.

A. Ask the client to describe the pain. B. Observe body language and movement. C. Identify effective pain relief measures. D. Provide a numeric pain scale.

Correct Answer is A

Explanation

A. Ask the client to describe the pain: This is the most crucial step. A good pain description can reveal characteristics like intensity, location, duration, and aggravating/relieving factors, all aiding in diagnosis.

B. Observe body language and movement: Nonverbal cues like grimacing, guarding (tensing muscles), or restlessness can indicate pain severity or location.

C. Identify effective pain relief measures: While this might be helpful later, it's not the primary way to assess pain quality initially.

D. Provide a numeric pain scale: Pain scales can be helpful for quantifying pain intensity, but a full description provides richer details.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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