The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

Bulges.

Nontender.

Tenderness.

Thrill.

Answer and Explanation

The Correct Answer is B

A. Bulges. Bulges might indicate abnormalities such as masses or hernias and are not considered normal findings.

B. Nontender. This is the expected finding in a healthy individual without thoracic abnormalities.

C. Tenderness. Tenderness might indicate inflammation, injury, or other underlying conditions and should be further assessed.

D. Thrill. Thrill refers to a vibrating sensation caused by turbulent blood flow and is not typically assessed during thoracic palpation.

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Correct Answer is D

Explanation

A. Longitudinal pigmented bands and red-brown linear streaks of recent onset. This description is more indicative of longitudinal melanonychia, which presents as pigmented bands along the length of the nail plate. It's not typically associated with finger clubbing.

B. Thinned, depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. This description suggests koilonychia, also known as spoon nails, which are characterized by thin, depressed nails with lateral edges tilting up. The mention of a fungal infection points to a different condition. It doesn't align with finger clubbing.

C. Transverse furrows and nail plate white spots that move forward with nail growth. This description corresponds to Beau's lines and leukonychia, which are not associated with finger clubbing. Beau's lines are transverse furrows or depressions in the nail plate, while leukonychia manifests as white spots or lines.

D. A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally. This description fits the characteristics of finger clubbing, where there's an increased nail base angle (greater than 180 degrees) and the nail plate is loosened at the distal-lateral edge, progressing proximally. This choice aligns with the assessment finding.

A. Teach the client to rotate the meal plate to visualize all the food on the plate. B. Instruct the client to lift the left extremities with the right hand when transferring. C. Implement precautions when the client is judging distances during transfers. D. Encourage the client to touch, wash, look at, and dress the affected side first.

Correct Answer is C

Explanation

A. Teach the client to rotate the meal plate to visualize all the food on the plate: While this intervention may be helpful for other reasons, it does not directly address the client’s difficulty walking in a straight line.

B. Instruct the client to lift the left extremities with the right hand when transferring: This intervention helps with weight-bearing and balance during transfers. It compensates for the left hemiplegia and promotes stability.

C. Implement precautions when the client is judging distances during transfers: This is crucial. Clients with hemiplegia may have impaired spatial awareness and difficulty judging distances. Strategies like using a gait belt, providing cues, or ensuring a clear path can help prevent falls. Implementing precautions during transfers helps prevent falls.

D. Encourage the client to touch, wash, look at, and dress the affected side first: While this approach promotes independence, it does not directly address the client’s gait instability.

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The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

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Naxlex Comprehensive Predictor Exams

The nurse inspects the client's fingernails. Which differentiating characteristics are observed in this assessment finding?

Correct Answer is D

Explanation

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Correct Answer is C

Explanation

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