What is an expected finding when palpating the sinuses?
No discomfort
Lumps less than 1 centimetre
Painful sensation behind the eyes
Heavy pressure
The Correct Answer is A
A) No discomfort: When palpating the sinuses, the expected finding is that there should be no discomfort. Healthy sinuses typically do not cause pain or tenderness during palpation, indicating that they are clear and not inflamed or infected.
B) Lumps less than 1 centimeter: While lumps may be found in various areas of the body, the presence of lumps in the sinus area during palpation is not a typical finding and may indicate an abnormality or concern that would require further evaluation.
C) Painful sensation behind the eyes: A painful sensation behind the eyes can indicate sinusitis or other sinus issues. It is not an expected finding during a normal examination of the sinuses, as healthy sinuses should not cause discomfort.
D) Heavy pressure: Heavy pressure is often a symptom associated with sinusitis or sinus congestion, but it is not an expected finding during a routine palpation of the sinuses. Healthy sinuses should not feel heavy or pressured during examination.
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Correct Answer is C
Explanation
A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.
B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.
C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.
D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.
Correct Answer is B
Explanation
A) To establish a rapport with the client and family: While building rapport is an important aspect of the health assessment process, it is not the primary purpose. Establishing a trusting relationship can enhance communication and the quality of care, but the overarching goal of the assessment extends beyond interpersonal dynamics.
B) To establish a database against which subsequent assessments can be measured: This is the primary purpose of a health assessment. By collecting comprehensive baseline data regarding a client's health status, the nurse creates a reference point for future evaluations. This allows for the monitoring of changes in the patient's condition over time, facilitating timely interventions when necessary.
C) To gather information for specialists to whom the client may be referred: Although gathering relevant information for potential referrals is beneficial, it is not the main purpose of the health assessment. The assessment primarily serves to inform the current healthcare team about the patient's status rather than focusing solely on future consultations.
D) To qualify the degree of pain the client may be experiencing: Assessing pain is an important component of a comprehensive health assessment, but it is just one aspect among many. The overall purpose of the health assessment encompasses a broader evaluation of physical, emotional, and social factors affecting the client's health.