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    Ngu Hesi Rn Compass Exit Proctored Exam

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

    Explanation & Rationale

    Rationale: A. Auscultation: Listening with a stethoscope is used for assessing heart, lung, or bowel sounds. It cannot detect papilledema, which is an optic disc swelling visible in the eye. B. Palpation: Feeling with the hands is useful for assessing tissue or organ enlargement, masses, or tenderness. Papilledema cannot be detected by palpation as it involves the optic disc inside the eye. C. Percussion: Percussion evaluates underlying structures by tapping, commonly used for lungs or abdomen. It does not provide information about the optic disc or intracranial pressure. D. Inspection: Direct visualization of the optic disc using an ophthalmoscope allows the nurse or healthcare provider to identify papilledema. Inspection is the appropriate technique to confirm optic disc swelling associated with increased intracranial pressure.

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