A nurse is collecting data from a client who is African American and has cholecystitis. Which of the following areas should the nurse inspect to monitor for the presence of jaundice?
Peri-umbilical area
Nail beds
Webbed areas of the fingers
Hard palate
The Correct Answer is D
Choice A: Peri-umbilical area. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The peri-umbilical area is the area around the navel, which is part of the skin. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.
Choice B: Nail beds. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The nail beds are part of the skin that can show jaundice, but they may also be affected by other factors such as anemia, cyanosis, or nail polish.
Choice C: Webbed areas of the fingers. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The webbed areas of the fingers are part of the skin that can show jaundice, but they may also be influenced by other factors such as temperature, circulation, or pressure.
Choice D: Hard palate. This is an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis, which is an inflammation of the gallbladder. Jaundice is a yellowish discoloration of the skin and mucous membranes due to elevated bilirubin levels in the blood. Bilirubin is a pigment that is produced from the breakdown of red blood cells and is normally excreted in bile. If the gallbladder or bile ducts are inflamed or obstructed, bile cannot flow into the duodenum and bilirubin accumulates in the blood and tissues. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Palpitations. This is not a finding that the nurse should expect in a client who has a new diagnosis of hypothyroidism, but rather a sign of hyperthyroidism, which is a condition that occurs when the thyroid gland produces too much thyroid hormone. Hyperthyroidism can cause palpitations due to increased cardiac output and heart rate.
Choice B: Weight gain. This is a finding that the nurse should expect in a client who has a new diagnosis of hypothyroidism, which is a condition that occurs when the thyroid gland does not produce enough thyroid hormone. The thyroid hormone regulates the metabolism of carbohydrates, proteins, and fats, and affects energy expenditure and body temperature. Hypothyroidism can cause weight gain due to decreased metabolic rate and increased fluid retention.
Choice C: Diaphoresis. This is not a finding that the nurse should expect in a client who has a new diagnosis of hypothyroidism, but rather a sign of hyperthyroidism. Hyperthyroidism can cause diaphoresis due to increased heat production and vasodilation.
Choice D: Protruding eyeballs. This is not a finding that the nurse should expect in a client who has a new diagnosis of hypothyroidism, but rather a sign of Graves’ disease, which is an autoimmune disorder that causes hyperthyroidism. Graves’ disease can cause protruding eyeballs due to inflammation and edema of the orbital tissues and muscles.
Correct Answer is B
Explanation
Choice A: Place the client on bedrest. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Placing the client on bedrest can increase the risk of complications such as thromboembolism, pressure ulcers, and muscle atrophy. The nurse should encourage the client to perform gentle exercises and change positions frequently.
Choice B: Apply warm blankets. This is an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Hypothyroidism is a condition that occurs when the thyroid gland does not produce enough thyroid hormone. Thyroid hormone regulates the metabolism of carbohydrates, proteins, and fats, and affects the energy expenditure and body temperature. Myxedema is a severe form of hypothyroidism that causes swelling of the skin and tissues due to accumulation of mucopolysaccharides. Applying warm blankets can help maintain the client’s body temperature and prevent hypothermia, which is a low body temperature.
Choice C: Check the client for weight loss. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Checking the client for weight loss can indicate hyperthyroidism, which is a condition that occurs when the thyroid gland produces too much thyroid hormone.
Hyperthyroidism can cause weight loss due to increased metabolic rate and appetite. The nurse should check the client for weight gain, which can indicate hypothyroidism due to decreased metabolic rate and fluid retention.
Choice D: Limit high-fiber foods. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Limiting high-fiber foods can cause constipation, which can worsen hypothyroidism symptoms such as bloating, abdominal pain, and fatigue. The nurse should encourage the client to eat high-fiber foods, such as fruits, vegetables, and whole grains, to promote bowel regularity and prevent constipation.
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