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 A

Explanation

A. Fetal growth and gestational age. Ultrasound during pregnancy is commonly used to assess fetal growth, development, and gestational age. It allows healthcare providers to monitor the health and progress of the pregnancy, as well as detect any potential issues or abnormalities.

B. Lecithin-sphingomyelin ratio. This ratio is typically assessed in amniotic fluid samples to predict fetal lung maturity, but it's not the primary reason for a routine ultrasound during pregnancy.

C. Chromosomal abnormalities. While some prenatal screening tests, such as nuchal translucency ultrasound or cell-free DNA testing, can help assess the risk of chromosomal abnormalities, a routine ultrasound is not primarily conducted for this purpose.

D. Sex and size of the infant. While ultrasound can reveal the sex of the baby and provide estimates of fetal size, these are secondary to the primary goal of assessing fetal growth and gestational age.

A. Stand behind the client to avoid intimidation. B. Turn on overhead lights while giving instructions. C. Provide handouts written at a 12th grade reading level. D. Use background music to promote relaxation.

Correct Answer is B

Explanation

A. Stand behind the client to avoid intimidation. This is not an appropriate teaching strategy. Standing behind a client can actually increase intimidation and anxiety, as it does not allow for direct eye contact and clear communication.

B. Turn on overhead lights while giving instructions. Proper lighting is essential for older adults, who may have visual impairments. Turning on overhead lights ensures that the client can clearly see the materials and the nurse, enhancing understanding and engagement during the teaching session.

C. Provide handouts written at a 12th grade reading level. Handouts for patient education should be written at a lower reading level, generally around the 5th to 6th grade level, to ensure comprehension by a broad audience, including those with limited literacy skills. A 12th grade reading level is too high for effective patient education for most adults.

D. Use background music to promote relaxation. Background music can be distracting rather than relaxing during educational sessions, especially for older adults who may have hearing impairments or cognitive issues. Clear and focused communication is more effective without additional auditory distractions.

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