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 C

Explanation

A: Apply a pulse oximeter to the foot. Continuous monitoring of oxygen saturation can help detect hypoxemia early, which can be a concern in post-term infants due to potential respiratory distress or meconium aspiration. However, while important, this is a monitoring measure and not an immediate corrective action for potential metabolic or respiratory issues directly associated with post-term birth.

B: Draw arterial blood gases. Arterial blood gases (ABGs) provide critical information about the newborn's acid-base balance, oxygenation, and ventilation status. Post-term infants are at risk for hypoxia and acidosis, often due to placental insufficiency or meconium aspiration. However, obtaining ABGs can be invasive and might not be the first-line immediate action unless there are signs of severe distress.

C: Obtain a capillary blood glucose. Post-term infants are at increased risk for hypoglycaemia due to increased glucose utilization and possible depletion of glycogen stores. Hypoglycaemia can lead to serious complications if not promptly identified and managed. Therefore, checking blood glucose levels is a critical, non-invasive, and immediate step to ensure metabolic stability and prevent complications such as seizures and brain injury.

D: Provide blow-by oxygen. Blow-by oxygen is used to provide supplemental oxygen in a non-invasive manner and can help in cases of mild respiratory distress. Post-term infants can be at risk for respiratory issues, including meconium aspiration syndrome. However, this is usually applied when there is evidence of respiratory distress and not as a routine measure without specific indications.

Correct Answer is "{\"xRanges\":[56.109375,86.109375],\"yRanges\":[109,139]}"

Explanation

To auscultate for the presence of a carotid artery bruit, the nurse should place the bell of the stethoscope over the carotid artery. Specifically, the nurse should place the bell of the stethoscope lightly on the skin just medial to the sternocleidomastoid muscle at the level of the thyroid cartilage. The carotid artery can be found in the neck, just lateral to the trachea and medial to the sternocleidomastoid muscle.

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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

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?

Correct Answer is "{\"xRanges\":[56.109375,86.109375],\"yRanges\":[109,139]}"

Explanation

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