A nurse is performing a physical assessment of a client's neck. Which assessment finding would the nurse consider expected?
The jugular veins are visibly distended when the client is sitting upright
The client reports tenderness when the thyroid gland is palpated
The thyroid gland is visibly enlarged
Full range of motion without pain or stiffness
The Correct Answer is D
Rationale:
A. The jugular veins should not be visibly distended when the client is sitting upright. Visible jugular vein distention in this position can indicate increased central venous pressure or heart failure, which is an abnormal finding.
B. Tenderness when palpating the thyroid gland is not expected. A healthy thyroid is typically non-tender. Pain or tenderness may indicate inflammation, infection (thyroiditis), or other pathology requiring further evaluation.
C. A visibly enlarged thyroid gland is abnormal. Enlargement (goiter) may indicate thyroid dysfunction, iodine deficiency, or other endocrine disorders, and is not considered an expected finding in a healthy client.
D. Full range of motion of the neck without pain or stiffness is an expected finding. This indicates normal musculoskeletal function of the cervical spine and surrounding structures, which is consistent with a healthy assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. This is a significant finding that may indicate a neurologic deficit such as stroke or spinal cord injury. While urgent, it is not immediately life-threatening unless associated with respiratory compromise. Nursing priority is determined by airway, breathing, circulation (ABCs) first.
B. Guarding suggests pain, possibly from abdominal pathology such as peritonitis, appendicitis, or internal bleeding. This requires prompt assessment, but unless it is causing airway or breathing compromise, it is secondary in priority.
C. This indicates respiratory distress, which is a potentially life-threatening condition. Shortness of breath compromises oxygenation, making it the highest priority according to the ABCs framework. The nurse should immediately assess airway, oxygen saturation, respiratory effort, and be prepared to provide supplemental oxygen or other interventions.
D. This finding indicates a stable and non-urgent condition. There is no immediate risk to airway, breathing, or circulation.
Correct Answer is C
Explanation
Rationale:
A. Inserting the otoscope deeply into the ear canal can cause discomfort, pain, or injury to the client’s ear. Proper technique requires gentle insertion just far enough to visualize the tympanic membrane without causing trauma.
B. Pulling the auricle downward and backward is appropriate for children under 3 years old, not adults. Using this technique on an adult may make visualization difficult and does not align with standard adult assessment guidelines.
C. Pulling the auricle upward and backward straightens the ear canal in adults, allowing proper visualization of the tympanic membrane. This technique reduces obstruction from the canal’s natural curve and facilitates accurate assessment while minimizing discomfort.
D. Asking the client to tilt the head forward is not necessary for otoscopic examination. The client should remain seated with the head in a neutral position while the nurse gently straightens the canal with the correct auricle maneuver. Tilting the head forward does not improve visualization.
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