The nurse performs the action shown in this image during the assessment of a client. What is the nurse assessing?
Intercostal spaces
Lymph nodes
Skin Turgor
Carotid Pulse
The Correct Answer is C
A) Intercostal spaces:
Assessing intercostal spaces typically involves palpating or inspecting the area between the ribs to check for abnormalities such as retractions or tenderness, usually conducted with the client sitting or standing.
B) Lymph nodes:
Palpation of lymph nodes, such as in the cervical region, involves using fingertips to gently feel for enlarged or tender nodes. This examination focuses on areas like the neck, underarms, and groin.
C) Skin Turgor:
The image depicts a nurse pinching the skin, likely on the chest or forearm, which is a common method to assess skin turgor. Skin turgor evaluation helps determine hydration status; if the skin remains tented and returns slowly to its original position, it indicates dehydration.
D) Carotid Pulse:
Assessing the carotid pulse involves palpating the carotid artery along the side of the neck to evaluate the strength and rhythm of the pulse. This is typically done using the pads of the fingers, not by pinching the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Nail Beds:
While peripheral cyanosis can cause bluish discoloration of the nail beds, central cyanosis is more indicative of systemic hypoxemia and is best assessed in areas with rich blood supply, such as the oral mucosa.
B. Sclera:
The sclera is more commonly used to assess for jaundice (yellowing) rather than cyanosis. Cyanosis is not typically visible in the sclera.
C. Oral Mucosa:
Central cyanosis is most accurately assessed in areas with high vascularization, such as the oral mucosa. This area provides a clear indication of oxygenation status and can reveal hypoxemia more reliably than peripheral sites.
D. Palms:
Similar to the nail beds, the palms can show signs of peripheral cyanosis but are not the primary site for assessing central cyanosis. The oral mucosa remains the best site for this assessment.
Correct Answer is C
Explanation
A) Loss of vision in one eye:
Loss of vision in one eye is not related to hyperopia (farsightedness). This condition could be due to various other causes such as retinal detachment, optic neuropathy, or trauma, but it does not describe the refractive error associated with hyperopia.
B) Clear vision of nearby objects, but difficulty seeing distant objects:
This description pertains to myopia (nearsightedness), where individuals can see nearby objects clearly but struggle with seeing distant objects. Hyperopia is the opposite, involving difficulty with near vision rather than distance vision.
C) Clear vision of distant objects, but difficulty seeing nearby objects:
Hyperopia, or farsightedness, is characterized by clear vision of distant objects while nearby objects appear blurry. This occurs because the eye's light focuses behind the retina rather than directly on it, making close-up tasks like reading challenging.
D) Blurry vision of both distant and nearby objects:
Blurry vision of both distant and nearby objects is not specific to hyperopia and may indicate other eye conditions such as astigmatism or severe refractive errors that affect overall visual acuity, rather than the specific issue of near vision seen in hyperopia.
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