A nurse palpates the neck using a three finger technique. what is the nurse assessing?
Trachea is midline
Location of the thyroid
Location of lymphnodes
Ability for client to swallow
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Epistaxis: Epistaxis, or a nosebleed, typically presents with the sudden onset of blood coming from one or both nostrils. Although a nosebleed can cause discomfort and a sense of obstruction, it does not typically present as difficulty breathing through one side of the nose. Epistaxis is more related to trauma, dry air, or nasal irritation rather than a structural issue causing airflow restriction.
B) Perforated septum: A perforated septum refers to a hole or tear in the nasal septum, the cartilage and bone that separates the two nasal passages. It may cause symptoms such as a whistling sound when breathing or increased susceptibility to infections, but difficulty breathing on one side of the nose alone isn't the most common symptom. A perforated septum is often associated with chronic drug use or injury, but it doesn't usually present with unilateral breathing difficulty unless it's very severe.
C) Deviated septum: A deviated septum occurs when the thin wall of bone and cartilage that divides the nasal cavity is displaced to one side. This condition is one of the most common causes of breathing difficulty on one side of the nose. The deviation can obstruct airflow, leading to symptoms like difficulty breathing through one nostril, congestion, or sinus infections. This diagnosis is most likely based on the patient's complaint.
D) Ankyloglossia: Ankyloglossia, also known as tongue-tie, refers to a condition where the frenulum (the membrane under the tongue) is abnormally short, restricting the tongue's movement. While it can cause feeding difficulties in infants or speech issues, it has no connection to nasal airflow or breathing problems. This diagnosis is unrelated to the symptoms described.
Correct Answer is B
Explanation
A) Bacterial: Bacterial infections in the mouth typically result in symptoms like foul odor, swelling, or pus, but they do not generally cause a black, hairy appearance on the tongue. A black, hairy tongue is more commonly associated with fungal overgrowth or other non-bacterial factors.
B) Fungal: A black, hairy tongue is often caused by an overgrowth of yeast or fungi, particularly Candida. This condition occurs when the normal balance of microorganisms in the mouth is disrupted, leading to the growth of fungi on the tongue’s papillae. These elongated, discolored papillae can trap food, bacteria, and dead cells, leading to a dark, furry appearance.
C) Parasite: Parasitic infections in the mouth are rare and usually cause symptoms such as sores, swelling, or difficulty swallowing, but they do not typically result in a black, hairy tongue. A parasitic infection would have a different set of symptoms and appearance.
D) Viral: Viral infections, such as those caused by the herpes simplex virus, can cause sores or ulcers in the mouth but do not typically cause a black, hairy appearance of the tongue. Viral infections might also cause symptoms like fever, pain, or swelling, but not this specific characteristic.
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