The nurse is using the finger pads of the hand to palpate a body part. Which finding would the nurse be best able to detect?
Temperature
Vibrations
Pulses
Fremitus
The Correct Answer is C
Choice A Reason:
The dorsal aspect of the hand, rather than the finger pads, is more sensitive to temperature due to its thinner skin. Therefore, while the finger pads can detect temperature, they are not the best tool for this purpose.
Choice B Reason:
Vibrations, such as those produced by vocal fremitus, are typically assessed using the ulnar edge or the palmar aspect of the hand, not the finger pads. The finger pads are sensitive but do not provide the best surface for detecting vibrations.
Choice C Reason:
The finger pads are densely innervated and are the most sensitive part of the hand, making them ideal for palpating pulses. Pulses are subtle and require a fine touch to assess properly, which is why the finger pads are the preferred area for this assessment.
Choice D Reason:
Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as someone speaks. It is best felt with the ball of the hand or the ulnar edge, not the finger pads.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The nasolacrimal sac is part of the tear drainage system. When a patient presents with excessive tearing, known as epiphora, it is important to assess for any obstruction in the lacrimal apparatus. The nasolacrimal sac can become blocked due to various reasons such as infection, inflammation, or structural abnormalities. Assessing this area can help determine if there is a blockage causing the tears to accumulate and overflow.
Choice B Reason:
Inspecting the palpebral conjunctiva is typically done if there is a complaint of eye pain or a sensation of a foreign body in the eye. While it is part of a comprehensive eye examination, it is not the first assessment to be performed for excessive tearing unless there are additional symptoms that suggest a problem with the conjunctiva.
Choice C Reason:
Testing the pupillary reaction to light is an assessment of the pupillary response and the function of the oculomotor nerve. This test is crucial when neurological issues are suspected or if there is a change in vision. However, it is not the primary assessment for excessive tearing without other associated symptoms.
Choice D Reason:
The eye positions test, which assesses eye muscle strength and cranial nerve function, is not necessary unless there are signs of problems with muscle strength, such as drooping. This test would not typically be the next step in assessing a patient with excessive tearing unless there are other indications of muscle or nerve impairment.
Correct Answer is A
Explanation
Choice A reason:
A formal hearing test, or audiometry, is the most comprehensive method for assessing hearing loss, which can be a side effect of ototoxic medications. These tests can detect both conductive and sensorineural hearing loss, providing a detailed profile of hearing function across different frequencies. For clients receiving ototoxic antibiotics, regular monitoring through formal hearing tests is recommended to detect any early signs of hearing impairment and to implement timely interventions.
Choice B reason:
The rubbing fingers test is a rudimentary hearing screening method where the examiner rubs their fingers together near the patient's ear, asking them to indicate when they hear the sound. While this test can be used as a quick check for hearing loss, it is not as sensitive or specific as formal audiometry and may not detect early or mild hearing loss caused by ototoxic drugs.
Choice C reason:
Tuning fork tests, such as the Weber and Rinne tests, are used to differentiate between conductive and sensorineural hearing loss. These tests can be useful in a clinical setting to provide immediate information about the type of hearing loss; however, they are not as comprehensive as formal hearing tests and may not be sufficient for monitoring ototoxicity.
Choice D reason:
The whisper hearing test involves the examiner whispering words or numbers and asking the patient to repeat them. This test can be useful for detecting significant hearing loss but may not be sensitive enough to detect the early stages of ototoxicity. Moreover, the test's accuracy can be affected by the examiner's voice level and the testing environment.
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