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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Use IV tube ports when injecting medications." Latex-free IV ports should be used instead of rubber stoppers found in some IV bags and vials.
B. "Remove medication from multi-dose vials with the stopper in place." Many vial stoppers contain latex, so the nurse should use single-dose vials or vials labeled as latex-free.
C. "Secure loose cords in stockinette with tape." Stockinettes are sometimes made with latex, posing a risk to the client. Non-latex materials should be used instead.
D. "Schedule the client's surgery as the last procedure of the day." Clients with latex allergies should be scheduled first to minimize exposure to airborne latex particles from gloves and equipment used earlier in the day.
Correct Answer is A
Explanation
A. Request a referral for an occupational therapist. An occupational therapist (OT) can help the client maintain independence by teaching adaptive techniques and providing assistive devices for ADLs, such as dressing, bathing, and eating.
B. Request a home health aide to perform the client's ADLs for them. While a home health aide can assist with ADLs, the goal is to promote independence, not to have someone do everything for the client.
C. Instruct family members to place the client in a nursing home. Placement in a nursing home is a complex decision based on multiple factors. The nurse should focus on interventions to support the client at home before considering long-term care.
D. Contact the client's pharmacy to change their medication doses. Nurses do not have the authority to change medication doses. Medication adjustments should be discussed with the prescribing provider if needed.
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