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 D
Explanation
Choice a reason:
Pigeon Chest, or pectus carinatum, is a condition where the breastbone is pushed outward, and the chest appears to protrude. It is not typically associated with a barrel-shaped chest, which is characterized by a rounded and bulging appearance.
Choice b reason:
Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus. While it can cause chest expansion, it does not lead to a barrel-shaped chest. The barrel-shaped chest is more indicative of a chronic condition rather than an acute infection like pneumonia.
Choice c reason:
Funnel Chest, or pectus excavatum, is a condition where the breastbone is sunken into the chest. Unlike a barrel-shaped chest, funnel chest gives the chest a depressed appearance.
Choice d reason:
COPD, or Chronic Obstructive Pulmonary Disease, is commonly associated with a barrel-shaped chest. This shape results from the chronic hyperinflation of the lungs due to obstructive lung disease, which causes the rib cage to remain expanded.
Correct Answer is C
Explanation
Choice a reason:
A firm toothbrush is not recommended for plaque removal as it can damage the gums and tooth enamel. Soft-bristled toothbrushes are preferred because they are effective at removing plaque while being gentle on the gums and enamel.
Choice b reason:
Brushing more than twice per day does not necessarily irritate the gums unless done with improper technique or with a hard-bristled toothbrush. It is important to brush gently with a soft-bristled toothbrush and to use fluoride toothpaste to maintain oral hygiene and prevent gingivitis.
Choice c reason:
Ensuring that dental restorations such as fillings and crowns fit well is crucial in preventing gingivitis. Poorly fitted restorations can trap food particles and bacteria, leading to plaque buildup and gum inflammation. Regular dental check-ups can help ensure that restorations remain intact and do not contribute to gingivitis.
Choice d reason:
Flossing should not be avoided even if there is bleeding at the gumline. Bleeding can be a sign of gingivitis, and flossing can help remove the plaque and bacteria causing the inflammation. If bleeding persists, it is important to consult a dentist.
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