During an assessment the nurse performs the action shown in this image. What is the purpose of this action?

Measure nerve function in the fingers

Monitor oxygen status

Determine capillary refill

Assess finger range of motion

Answer and Explanation

The Correct Answer is C

A. Measure nerve function in the fingers:

Measuring nerve function typically involves different assessments, such as checking sensation or performing nerve conduction studies. The action in the image is not indicative of a nerve function test.

B. Monitor oxygen status:

Monitoring oxygen status is usually done with a pulse oximeter, which is placed on the finger but does not involve the manual action shown in the image. The image depicts a manual technique, not a pulse oximetry procedure.

C. Determine capillary refill:

The action shown in the image is a technique used to determine capillary refill time. The nurse presses on the nail bed until it blanches and then releases it to see how quickly the color returns. This assesses peripheral perfusion and can indicate circulatory status.

D. Assess finger range of motion:

Assessing finger range of motion involves moving the fingers through their full range of motion, such as flexing, extending, abducting, and adducting them. The action in the image does not reflect these movements and is more indicative of assessing capillary refill.

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Correct Answer is ["A","C","D"]

Explanation

A) Age 55 years:

Advancing age is a risk factor for skin cancer. As individuals age, the cumulative exposure to UV radiation increases, and the skin's ability to repair damage decreases, leading to a higher risk of skin cancer.

B) Yellow palms of the hands:

Yellow palms are typically associated with conditions like carotenemia or jaundice, not skin cancer. This symptom does not indicate an increased risk of developing skin cancer.

C) Light-colored hair:

Individuals with light-colored hair, especially those with fair skin and light eyes, are at higher risk for skin cancer. They often have less melanin, which provides some protection against UV radiation, increasing their susceptibility to damage from the sun.

D) Actinic keratosis on face:

Actinic keratosis is a precancerous skin lesion caused by long-term sun exposure. It is considered a significant risk factor for developing squamous cell carcinoma, a type of skin cancer. Presence of actinic keratosis should prompt careful monitoring and possibly treatment.

E) Poor skin turgor:

Poor skin turgor typically indicates dehydration or aging but is not directly related to an increased risk of skin cancer. It is more of a general indicator of skin and overall health rather than a specific risk factor for cancer.

A. to prevent further dehydration B. to assist the client to feel more comfortable C. to observe the movement of the thyroid gland D. to promote the nurse-client relationship

Correct Answer is C

Explanation

A. To prevent further dehydration:

While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.

B. To assist the client to feel more comfortable:

Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.

C. To observe the movement of the thyroid gland:

Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.

D. To promote the nurse-client relationship:

Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.

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During an assessment the nurse performs the action shown in this image. What is the purpose of this action?

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Naxlex Comprehensive Predictor Exams

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

Correct Answer is C

Explanation

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