A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?

Conjunctiva

Sclera of the eye

Back of the neck

Palms of the hands

Answer and Explanation

The Correct Answer is B

Choice A Reason:
The conjunctiva can sometimes appear yellow in individuals with jaundice; however, it is not the most reliable area to inspect for jaundice. The conjunctiva may be affected by other factors such as environmental irritants or infections, which can alter its appearance.

Choice B Reason:
The sclera of the eye is the most reliable area to inspect for jaundice. The yellowing of the sclera, also known as scleral icterus, is a key indicator of jaundice. The sclera's white background provides a clear contrast, making any yellow discoloration more noticeable. This is particularly true in darker-skinned individuals, where skin changes may be less apparent.

Choice C Reason:
The back of the neck is not a reliable area to inspect for jaundice. Skin pigmentation and lighting can affect the visibility of yellowing, making it an unreliable indicator. Additionally, the back of the neck may have other skin changes unrelated to jaundice that could confuse the assessment.

Choice D Reason:
The palms of the hands are not the most reliable area to inspect for jaundice. While the palms may show yellowing, they are subject to various external factors such as manual labor or exposure to substances that can affect their color. Moreover, the palms' skin may be thicker and less transparent, making subtle changes in color more difficult to detect.

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Correct Answer is B

Explanation

Choice a reason:
Educational Prevention is not a recognized level of prevention in healthcare. While education is a key component in all levels of prevention, it is not a standalone category. Education is typically included in primary prevention as it involves informing the public about health practices to prevent the onset of disease.

Choice b reason:
Tertiary Prevention is the level of prevention that aims to manage and treat an existing disease to prevent further complications or deterioration. In the case of immobile stroke patients, tertiary prevention would involve measures to prevent skin breakdown and other complications associated with immobility and the stroke's long-term effects.

Choice c reason:
Secondary Prevention involves early detection and prompt intervention to prevent the progression of a disease. For stroke patients, secondary prevention might include monitoring for signs of skin breakdown so that early treatment can be initiated. However, the scenario described focuses on managing an existing condition rather than early detection.

Choice d reason:
Primary Prevention aims to prevent the disease or injury before it occurs. This would involve strategies to prevent strokes in the first place, such as controlling high blood pressure or encouraging healthy lifestyle changes. It does not directly relate to the prevention of skin breakdown in patients who have already had a stroke.

A. Tracheal B. Vesicular C. Bronchovesicular D. Bronchial

Correct Answer is B

Explanation

Choice A Reason:
Tracheal sounds are harsh, high-pitched breath sounds typically heard over the trachea in the neck. They are not expected to be heard over the peripheral lung fields of a young adult during a routine lung auscultation.

Choice B Reason:
Vesicular breath sounds are the normal sounds heard over most of the lung fields. They are characterized by a soft, low-pitched, rustling sound during inhalation and are softer during exhalation. These sounds are created by air moving through the smaller airways such as the bronchioles and alveoli.

Choice C Reason:
Bronchovesicular sounds are heard over the major bronchi and are characterized by a moderate pitch and intensity. They are typically heard between the first and second intercostal spaces at the sternal border anteriorly and between the scapulae posteriorly, not over most of the lung fields.

Choice D Reason:
Bronchial breath sounds are high-pitched and louder than vesicular sounds, with a hollow quality, and are normally heard over the manubrium. If heard over the peripheral lung fields, they may indicate lung consolidation or other abnormalities.

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A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

Correct Answer is B

Explanation

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

Correct Answer is B

Explanation

While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

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Prior to completing the physical examination of a patient post motor vehicle crash, the ER nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

A client with a history of COPD is being assessed. When the nurse percusses the client's chest, which characteristic sound is expected?

The nurse read the patient's health history and noted cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

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