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 D
Explanation
A. Consult the social worker to speak with the client about support groups. While a social worker can be a valuable resource, advocacy involves the nurse directly supporting the client rather than referring them to another professional as the primary action.
B. Help the client make decisions about their treatment by providing them with your opinions. Advocacy means ensuring the client has accurate, unbiased information to make informed decisions, not influencing them with personal opinions.
C. Provide the client with a computer to look up questions they have about their diagnosis. While access to information is important, the nurse should provide evidence-based resources and ensure the client receives accurate, professional guidance.
D. Avoid discussing alternative treatments that may have the potential to harm the client. Advocacy includes ensuring the client is aware of safe and effective treatment options while protecting them from misinformation or potentially harmful alternatives.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
- Oxygen Saturation (90%) – This is a drop from the initial 95% and indicates potential hypoxia. The increased respiratory rate and depth may be compensatory mechanisms.
- Behavioral Findings ("I feel like something is wrong.") – Clients experiencing early signs of deterioration often report a sense of unease. This, combined with agitation, could indicate worsening hypovolemia or hypoxia.
The client's low hemoglobin (8.3 g/dL) and hematocrit (32%) suggest significant blood loss during surgery, which could contribute to hypoxia and hemodynamic instability. Immediate follow-up is needed to assess for potential ongoing bleeding, oxygenation issues, or early signs of shock.
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