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. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. This action is used to assess breath sounds, not tactile fremitus.

B. Looking at the client from the side, observe the size and shape of the chest wall. This action helps in assessing the general appearance and shape of the chest but does not assess tactile fremitus.

C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. This is the correct technique to assess tactile fremitus. Increased fremitus can indicate consolidation, as in pneumonia.

D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. This action is associated with palpating for crepitus, not assessing tactile fremitus.

A. A bubbling sound heard during inspiration and expiration in the central airways. B. A crowing noise heard during inspiration over the trachea. C. Popping, nonmusical sounds heard in the lung bases, usually during inspiration. D. Superficial squeaking or grating sounds heard during inspiration and expiration.

Correct Answer is C

Explanation

A. A bubbling sound heard during inspiration and expiration in the central airways: This description is accurate. Crackles (also called rales) are often heard in conditions like pulmonary edema or pneumonia.

B. A crowing noise heard during inspiration over the trachea: This description refers to stridor, not crackles. Stridor occurs due to upper airway obstruction.

C. Popping, non-musical sounds heard in the lung bases, usually during inspiration: This description is accurate for crackles. They occur due to fluid or secretions in the alveoli.

D. Superficial squeaking or grating sounds heard during inspiration and expiration: This description refers to wheezes, not crackles. Wheezes are associated with narrowed airways.

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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 tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is C

Explanation

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

Correct Answer is C

Explanation

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