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Asking how long the client has had the problem is a history-taking question. It helps establish the duration of symptoms but does not directly assess thyroid enlargement. Thyroid enlargement is best evaluated through physical examination techniques such as palpation and observation during swallowing.

Inquiring about current medications is important because certain drugs can affect thyroid function. However, this question is part of a health history assessment, not a direct physical examination maneuver to check for thyroid enlargement.

Asking about the type of salt used in cooking relates to iodine intake, which can influence thyroid health. While relevant to thyroid disease risk factors, it does not directly assess thyroid enlargement during a physical exam.

Increased hair on the face can occur in older women due to hormonal changes, particularly decreased estrogen levels. However, this is not a universal or expected age-related change for all older adults, and it is more of a secondary manifestation rather than a primary age-related change.

Skin thickening is not an expected age-related change. In fact, aging is associated with thinning of the skin due to decreased collagen, elastin, and subcutaneous fat. This thinning makes the skin more fragile and prone to injury.

The size of the ears does not decrease with age. In fact, ears and nose may appear larger or elongated due to continued cartilage growth and loss of skin elasticity. Therefore, decreased ear size is not an expected age-related change.

Documenting the sound the nurse thought was heard without certainty is inappropriate. Documentation must be accurate and objective. If the nurse is unsure, recording uncertain findings could mislead other healthcare providers and compromise patient care.

Asking an unlicensed assistive personnel (UAP) to listen to the client’s lungs is inappropriate because UAPs are not trained or authorized to perform auscultation or interpret clinical findings. Their role is limited to basic care tasks, not advanced assessments.

Notifying the healthcare provider without confirming the finding may lead to unnecessary interventions or miscommunication. Providers rely on accurate nursing assessments, so verification by another nurse should occur before escalation.
 

Tinnitus refers to ringing or buzzing in the ears. While tinnitus can occur with aging, it is not the definition of presbycusis. Presbycusis specifically refers to age-related hearing loss, not the perception of abnormal sounds.

Conductive hearing loss occurs when sound waves are blocked from reaching the inner ear due to problems in the outer or middle ear, such as wax buildup or otitis media. Presbycusis is not conductive; it is sensorineural in nature.

Nystagmus is an involuntary rhythmic movement of the eyes, often associated with vestibular or neurological disorders. It is unrelated to presbycusis and does not describe age-related hearing loss.

Reading line 5 correctly from 30 feet is not a standard measure of visual acuity. The Snellen chart is calibrated for 20 feet, not 30 feet, so this finding would not be considered a normal or valid assessment.

Reading letters with both eyes open at 30 feet is not a proper Snellen chart procedure. The test is performed at 20 feet and usually with one eye covered at a time to assess each eye individually.

Requiring glasses to read line 10 from a distance of 10 feet indicates impaired vision, not normal visual acuity. Line 10 represents very small letters, and difficulty reading them even at a short distance suggests reduced visual sharpness.

Fingertips are more sensitive to fine tactile discrimination such as texture or pulse assessment, but they are not the best for detecting temperature changes. The nerve endings in fingertips are specialized for touch, not thermal sensitivity.

The palm of the hand is not as sensitive to temperature changes compared to the back of the hand. The palm is better suited for grasping and pressure, not subtle thermal detection.

The pads of the fingers are useful for palpating pulses and assessing texture but are not as effective for detecting temperature changes. They lack the sensitivity to thermal variations compared to the back of the hand.

Counting the carotid pulse for one minute is not appropriate because the carotid pulse is not used for detailed rhythm assessment. It is mainly used to assess circulation in emergencies.

Counting the femoral pulse for one minute is not appropriate either. The femoral pulse is used to assess circulation in the lower extremities, not cardiac rhythm irregularities.

Using a doppler to count the apical pulse is unnecessary unless pulses are very faint or difficult to palpate. In this case, the nurse can directly auscultate the apical pulse without additional equipment.

Telling the client they will lose their eye is inappropriate and fear-inducing. It does not provide therapeutic communication and may cause unnecessary anxiety.

Asking why the client forgot is judgmental and does not promote open communication. It may make the client feel guilty rather than supported.

Suggesting over-the-counter eye drops is not appropriate without further assessment. Eye irritation related to contact lenses can lead to infections or corneal damage, which require medical evaluation rather than self-treatment.

Pleural friction rub is a grating sound heard during both inspiration and expiration, caused by inflamed pleural surfaces rubbing together. It does not sound like popping and is distinctly different from crackles.

Bronchovesicular sounds are normal breath sounds heard over the major bronchi. They are medium-pitched and not popping in nature. Documenting popping sounds as bronchovesicular would be inaccurate.

Crepitus refers to a crackling sensation felt under the skin due to air trapped in subcutaneous tissue, not a sound heard during auscultation of the lungs. It is palpated, not auscultated.
 

A blood pressure of 90/42 mmHg indicates hypotension, which can occur with fluid volume deficiency. However, the heart rate of 62 beats per minute is too low to be consistent with the expected compensatory tachycardia. In hypovolemia, the body typically increases heart rate to maintain cardiac output.

A blood pressure of 145/92 mmHg with a heart rate of 68 beats per minute indicates hypertension, not fluid volume deficiency. This finding is inconsistent with hypovolemia, which usually causes low blood pressure and tachycardia.

A blood pressure of 162/82 mmHg with a heart rate of 114 beats per minute indicates hypertension with tachycardia. This is not typical of fluid volume deficiency, which causes low blood pressure rather than elevated blood pressure.