A nurse palpates the neck using a three finger technique. what is the nurse assessing?

A) Subconjunctival hemorrhage: A subconjunctival hemorrhage occurs when small blood vessels in the conjunctiva (the clear membrane covering the white part of the eye) rupture, allowing blood to leak into the space between the conjunctiva and sclera. This results in a defined, bright red area on the sclera, and it can occur due to increased pressure within the eye, such as from coughing, sneezing, or straining. The condition is generally benign and resolves on its own, typically without pain or changes in vision.

B) Ptosis: Ptosis refers to drooping of the upper eyelid, often due to muscle weakness or nerve issues. This condition affects the eyelid position and does not cause a reddened area of the sclera or leakage of blood from vessels. Ptosis would not be associated with the findings described in the question.

C) Exophthalmos: Exophthalmos is the abnormal protrusion of the eyeball, often seen in thyroid eye disease or Graves' disease. While it affects the position of the eyes, it does not cause leakage of blood or redness in the sclera. This condition is more related to changes in the orbit or eye socket rather than bleeding from small blood vessels.

D) Astigmatism: Astigmatism is a refractive error caused by an irregular shape of the cornea or lens. It results in blurry or distorted vision but does not cause redness, bleeding, or changes to the sclera. This visual condition is unrelated to the physical changes described in the question.

A) Trachea is midline: Palpating the neck using a three-finger technique is not typically used to assess the position of the trachea. The trachea's position is assessed by placing one finger on each side of the trachea and gently palpating to check for any deviation from the midline. This technique is different from using three fingers to assess the thyroid.

B) Location of the thyroid: The three-finger technique is often used by nurses to palpate the thyroid gland. This method helps assess the size, shape, and consistency of the thyroid as well as to check for any enlargement (goiter) or tenderness. The technique is used to help guide the nurse’s fingers to the correct area for palpating the thyroid gland, typically located just below the Adam’s apple in the neck.

C) Location of lymph nodes: The location of lymph nodes is assessed by palpating different areas of the neck using the pads of the fingers or a gentle circular motion. The three-finger technique is not typically used to assess lymph nodes. Instead, lymph nodes are individually palpated with one or two fingers to feel for enlargement or tenderness.

D) Ability for client to swallow: Swallowing ability is assessed by observing the patient while they swallow fluids or food and by asking about any difficulty with swallowing (dysphagia). The three-finger technique does not assess swallowing directly; it is a method used for palpating structures in the neck like the thyroid.