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 D
Explanation
A) Cataracts: Cataracts are a condition where the lens of the eye becomes cloudy, leading to blurred vision. While cataracts can impact vision, they do not cause fixed, dilated pupils. Cataracts would typically affect the clarity of vision rather than pupil size and response.
B) Miosis: Miosis refers to constricted pupils that are smaller than normal, typically less than 2 mm in size. The finding described in the question (fixed and 7 mm) is the opposite of miosis, which would indicate excessively small pupils.
C) Astigmatism: Astigmatism is a refractive error caused by an irregular shape of the cornea or lens, resulting in blurry vision. It is unrelated to the size or responsiveness of the pupils and does not cause fixed or dilated pupils, making it an inappropriate choice for this finding.
D) Mydriasis: Mydriasis refers to the dilation of the pupils, typically greater than 6 mm in size. When the pupils are fixed and dilated (7 mm, as described), this condition is termed mydriasis. It can occur due to various factors such as certain medications, trauma, or neurological issues. The nurse should document this finding as mydriasis and notify the healthcare provider for further assessment.
Correct Answer is A
Explanation
A) At the base of the skull: The occipital lymph nodes are located at the base of the skull, just above the nape of the neck. The nurse should use a gentle circular motion to palpate the area where these lymph nodes are found. This is the correct location to assess for tenderness, swelling, or abnormalities in the occipital lymph nodes.
B) In front of the ears: The lymph nodes located in front of the ears are known as the preauricular lymph nodes. These are not the occipital lymph nodes. The preauricular nodes are assessed by palpating just in front of the ear, not at the base of the skull.
C) Under the mandible: The submandibular lymph nodes are located under the mandible (lower jaw). These nodes are not the occipital lymph nodes. The nurse would need to palpate under the jawline to assess the submandibular area.
D) Above the clavicles: The supraclavicular lymph nodes are located above the clavicles (collarbones), and they are not the occipital lymph nodes. This area is assessed separately to check for lymph node enlargement or abnormal findings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today