When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?
to prevent further dehydration
to assist the client to feel more comfortable
to observe the movement of the thyroid gland
to promote the nurse-client relationship
The Correct Answer is C
A. To prevent further dehydration:
While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.
B. To assist the client to feel more comfortable:
Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.
C. To observe the movement of the thyroid gland:
Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.
D. To promote the nurse-client relationship:
Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "I do not eat salty foods and snacks": This statement indicates the client's dietary habits and, while it can impact overall health, it does not necessarily require immediate validation unless there is reason to doubt its accuracy or it is related to a specific health concern being addressed.
B) "My rings are not fitting on my fingers like they usually do": This statement suggests a change in the client's physical condition, likely indicating fluid retention or edema. This symptom requires validation as it could signify an underlying issue such as heart failure, kidney problems, or other medical conditions that need prompt attention.
C) "I exercise about 20 minutes a day by walking": This statement reflects the client's physical activity routine. While it's important for assessing overall health and fitness, it does not demand immediate validation unless related to a specific health issue.
D) "High blood pressure is present in my mother & grandmother": This statement provides valuable family history information, which is important for assessing genetic risk factors. However, it does not require urgent validation compared to physical changes indicating potential health problems.
Correct Answer is B
Explanation
A. Improved wound healing:
While silver sulfadiazine is used to promote wound healing by preventing and treating infections in burn victims, this is not an adverse reaction. This is an intended therapeutic effect of the medication.
B. Allergic reaction in patients with sulfa allergies:
Silver sulfadiazine contains sulfa, and patients who have a sulfa allergy may experience an allergic reaction. This can range from mild skin rashes to severe systemic reactions and is considered a significant adverse reaction.
C. Delayed wound healing:
Silver sulfadiazine is generally used to promote wound healing by preventing bacterial infections. Delayed wound healing is not a common adverse reaction but may occur in some cases due to other underlying factors or if the medication is not effective against certain bacteria.
D. Increased risk of infection:
The primary purpose of silver sulfadiazine is to reduce the risk of infection in burn wounds. An increased risk of infection would indicate a failure of the medication, not an adverse reaction. The correct potential adverse reaction is an allergic response in patients with a known sulfa allergy.
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