A nurse is preparing to assess a client's thyroid gland. Which of the following actions should the nurse plan to take?
Instruct the client to take small sips of water.
Ask the client to hyperextend their neck during palpation.
Inspect the isthmus as the client holds their breath for 5 seconds.
Assist the client to a supine position prior to the assessment.
The Correct Answer is A
A. "Instruct the client to take small sips of water."
Having the client take small sips of water helps the nurse observe the thyroid gland as it moves up and down with swallowing, making abnormalities more noticeable.
B. "Ask the client to hyperextend their neck during palpation."
The client should slightly extend (not hyperextend) their neck to relax the muscles and allow for better palpation of the thyroid gland.
C. "Inspect the isthmus as the client holds their breath for 5 seconds."
The thyroid gland is best observed during swallowing, not by holding the breath.
D. "Assist the client to a supine position prior to the assessment."
Thyroid assessment is performed with the client in a sitting or standing position, not lying down.
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Related Questions
Correct Answer is D
Explanation
A. "Direct all communication through the client's family." While family members may assist in communication, they may omit, alter, or misunderstand medical information. Using a trained medical interpreter ensures accurate and confidential communication.
B. "Limit instructions to simple and short one-sentence instructions." While clear, simple instructions are helpful, language barriers still exist. This does not fully address the client’s difficulty in understanding.
C. "Ask a coworker who speaks the client's language to translate information." A coworker may not be a certified medical interpreter and could misinterpret critical information. Medical translation should always be done by a qualified interpreter.
D. "Find an available interpreter to help with communication." A trained medical interpreter provides accurate, unbiased, and professional translation, ensuring that the client fully understands their care and can make informed decisions.
Correct Answer is C
Explanation
A. "Bladder capacity decreases in older adults." While bladder capacity does decrease with age, this alone does not directly increase UTI risk.
B. "The urethral sphincter functions less efficiently." Although sphincter function may decline, this typically leads to incontinence rather than urinary retention, which is the main UTI risk factor.
C. "Decreased bladder tone can cause urinary retention." Urinary retention leads to stasis of urine, promoting bacterial growth and increasing UTI risk.
D. "The ability to concentrate urine decreases." Decreased ability to concentrate urine does not directly cause UTIs, though it may lead to dehydration, which could contribute to UTI risk indirectly.
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