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) Accessibility:
Accessibility refers to the client's ability to obtain food, which is crucial for nutritional status, especially for someone who lives alone and cannot drive. Difficulty in accessing grocery stores or markets can limit the variety and availability of nutritious food options, potentially leading to poor nutritional intake.
B) Food preparation:
Food preparation skills are important, but if the client has difficulty accessing food in the first place (due to transportation limitations), their ability to prepare meals becomes secondary. Accessibility to food sources is a more immediate concern for nutritional status.
C) Food preferences:
While food preferences can influence dietary choices, the ability to access food is a more fundamental issue that directly impacts nutritional intake, especially for someone who lives alone and has limited mobility.
D) Finances:
Financial constraints can certainly affect food choices and access to nutritious options. However, in this scenario, the primary concern is the physical accessibility to food sources, which directly impacts the client's ability to maintain adequate nutrition.
Correct Answer is C
Explanation
A) At the angle of the mandible:
Lymph nodes located at the angle of the mandible are the submandibular lymph nodes, not the occipital lymph nodes. These nodes are situated below the jawline and are assessed when looking for infections or abnormalities in the oral cavity and throat.
B) Temporal area:
The temporal area is not a typical location for lymph node palpation. This region is primarily related to the temporal artery and muscles, not to lymph nodes. Thus, palpating for lymph nodes here would not be relevant.
C) The posterior base of the skull:
The occipital lymph nodes are located at the posterior base of the skull, near the nape of the neck. These nodes drain the scalp and are assessed when there are scalp infections or other related conditions.
D) Area in front of the ears:
The lymph nodes in front of the ears are the preauricular lymph nodes. These nodes drain the eyes and the surrounding skin. They are not the occipital lymph nodes, which are situated at the back of the head.
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