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 A
Explanation
a) The patient is unable to see in half of the visual field (same visual field) in each eye:
Homonymous hemianopsia is a condition where there is a loss of vision in the same side of the visual field in both eyes. This occurs due to damage to the visual pathways after the optic chiasm, often from a stroke or brain injury, resulting in the loss of either the right or left visual field in both eyes.
b) The patient can see from one eye but not through the other one:
This description fits a condition called monocular blindness, which is typically caused by damage to the optic nerve before it reaches the optic chiasm. Homonymous hemianopsia involves both eyes and specific visual fields, not complete loss of vision in one eye.
c) The patient is unable to see in half of the visual field (opposite visual field) in each eye:
This option describes bitemporal hemianopsia, which results in loss of vision in the outer (temporal) fields of both eyes and is often due to damage at the optic chiasm. Homonymous hemianopsia involves the same side of the visual field in both eyes, not the opposite visual fields.
d) No visual impairment:
Homonymous hemianopsia is characterized by significant visual impairment, specifically the loss of half the visual field in both eyes on the same side. Therefore, it is incorrect to say there is no visual impairment with this condition.
Correct Answer is D
Explanation
A) Dysphagia:
Dysphagia refers to difficulty swallowing and is typically associated with conditions affecting the esophagus or neuromuscular function. While it can coexist with other symptoms, it does not directly explain hoarseness, fatigue, and weight gain as hypothyroidism does.
B) Gingivitis:
Gingivitis is an inflammation of the gums due to plaque buildup. It primarily affects oral health, causing redness, swelling, and bleeding of the gums. It is not associated with systemic symptoms like hoarseness, fatigue, or weight gain.
C) Aphthous ulcers:
Aphthous ulcers, also known as canker sores, are small, painful lesions that develop in the mouth. They are typically caused by stress, minor injury, or certain foods. These ulcers do not explain the systemic symptoms described by the client.
D) Hypothyroidism:
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. Symptoms include hoarseness, fatigue, weight gain, dry skin, and cold intolerance. The combination of these symptoms in the client's history makes hypothyroidism the most likely cause.
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