A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?
Conjunctiva
Sclera of the eye
Back of the neck
Palms of the hands
The Correct Answer is B
Choice A Reason:
The conjunctiva can sometimes appear yellow in individuals with jaundice; however, it is not the most reliable area to inspect for jaundice. The conjunctiva may be affected by other factors such as environmental irritants or infections, which can alter its appearance.
Choice B Reason:
The sclera of the eye is the most reliable area to inspect for jaundice. The yellowing of the sclera, also known as scleral icterus, is a key indicator of jaundice. The sclera's white background provides a clear contrast, making any yellow discoloration more noticeable. This is particularly true in darker-skinned individuals, where skin changes may be less apparent.
Choice C Reason:
The back of the neck is not a reliable area to inspect for jaundice. Skin pigmentation and lighting can affect the visibility of yellowing, making it an unreliable indicator. Additionally, the back of the neck may have other skin changes unrelated to jaundice that could confuse the assessment.
Choice D Reason:
The palms of the hands are not the most reliable area to inspect for jaundice. While the palms may show yellowing, they are subject to various external factors such as manual labor or exposure to substances that can affect their color. Moreover, the palms' skin may be thicker and less transparent, making subtle changes in color more difficult to detect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The primary purpose of health assessment is to collect, analyze, and interpret data to identify the patient’s health status and needs, as well as to develop and implement appropriate nursing interventions to address these needs. It is a systematic process that is fundamental in promoting the health and well-being of patients. This involves a comprehensive evaluation of the patient's physical, psychological, and social health. Gathering this information is crucial for creating a care plan that addresses the individual needs of the client.
Choice B reason:
While health assessments can aid physicians in diagnosing illness, they are not solely for the purpose of diagnosis without further testing. Health assessments may indicate the need for additional tests to confirm a diagnosis. The nurse's role includes supporting the diagnostic process, but it is not the primary purpose of health assessment.
Choice C reason:
Health assessments are not meant to be subjective or based on the nurse's personal views and beliefs. The assessments are conducted to objectively determine the health status of a client, which then informs evidence-based practice and care planning. Personal biases should not influence the management of a client's illness.
Choice D reason:
Making judgments about a client's lifestyle and behaviors is not the primary purpose of health assessment. While lifestyle and behaviors may be assessed as part of understanding the client's overall health status, the goal is not to judge but to understand how these factors may impact the client's health and to provide education and support for healthy changes if needed.
Correct Answer is A
Explanation
Choice A reason:
A formal hearing test, or audiometry, is the most comprehensive method for assessing hearing loss, which can be a side effect of ototoxic medications. These tests can detect both conductive and sensorineural hearing loss, providing a detailed profile of hearing function across different frequencies. For clients receiving ototoxic antibiotics, regular monitoring through formal hearing tests is recommended to detect any early signs of hearing impairment and to implement timely interventions.
Choice B reason:
The rubbing fingers test is a rudimentary hearing screening method where the examiner rubs their fingers together near the patient's ear, asking them to indicate when they hear the sound. While this test can be used as a quick check for hearing loss, it is not as sensitive or specific as formal audiometry and may not detect early or mild hearing loss caused by ototoxic drugs.
Choice C reason:
Tuning fork tests, such as the Weber and Rinne tests, are used to differentiate between conductive and sensorineural hearing loss. These tests can be useful in a clinical setting to provide immediate information about the type of hearing loss; however, they are not as comprehensive as formal hearing tests and may not be sufficient for monitoring ototoxicity.
Choice D reason:
The whisper hearing test involves the examiner whispering words or numbers and asking the patient to repeat them. This test can be useful for detecting significant hearing loss but may not be sensitive enough to detect the early stages of ototoxicity. Moreover, the test's accuracy can be affected by the examiner's voice level and the testing environment.
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