During an assessment the nurse performs the action shown in this image. What is the purpose of this action?
Measure nerve function in the fingers
Monitor oxygen status
Determine capillary refill
Assess finger range of motion
The Correct Answer is C
A. Measure nerve function in the fingers:
Measuring nerve function typically involves different assessments, such as checking sensation or performing nerve conduction studies. The action in the image is not indicative of a nerve function test.
B. Monitor oxygen status:
Monitoring oxygen status is usually done with a pulse oximeter, which is placed on the finger but does not involve the manual action shown in the image. The image depicts a manual technique, not a pulse oximetry procedure.
C. Determine capillary refill:
The action shown in the image is a technique used to determine capillary refill time. The nurse presses on the nail bed until it blanches and then releases it to see how quickly the color returns. This assesses peripheral perfusion and can indicate circulatory status.
D. Assess finger range of motion:
Assessing finger range of motion involves moving the fingers through their full range of motion, such as flexing, extending, abducting, and adducting them. The action in the image does not reflect these movements and is more indicative of assessing capillary refill.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Snellen chart:
The Snellen chart is used to assess distance vision, not near vision. It consists of letters or symbols arranged in rows, with the client typically asked to read from a specific distance to test visual acuity.
B) Penlight:
A penlight is primarily used to assess pupillary reactions and near vision tasks such as accommodation. It helps examine how the pupils respond to light and how well the eyes focus on near objects.
C) Magazine:
A magazine or similar reading material is commonly used to assess near vision. Clients are asked to read the text at a comfortable distance, evaluating their ability to focus on close-up objects and the clarity of their vision.
D) Ophthalmoscope:
An ophthalmoscope is used to examine the interior structures of the eye, such as the retina and optic nerve head. It is not used for assessing near vision but rather for diagnosing conditions affecting the eye's internal structures.
Correct Answer is A
Explanation
(a) Liver Disease:
Pitting edema is commonly seen in liver disease, especially in conditions like cirrhosis. Liver disease can lead to hypoalbuminemia, where low levels of albumin in the blood cause fluid to leak into the interstitial spaces, resulting in edema. Additionally, liver disease often leads to portal hypertension, which can also contribute to the development of edema.
(b) Diabetes mellitus:
While diabetes can cause complications such as diabetic nephropathy, which may lead to fluid retention, pitting edema is not a primary symptom directly associated with diabetes mellitus. Diabetic patients may develop edema due to kidney issues, but it is not as directly associated as with liver disease.
(c) End Stage Renal Disease:
End-stage renal disease (ESRD) can indeed cause significant fluid retention and edema, including pitting edema. The kidneys' inability to excrete excess fluid leads to its accumulation in tissues. However, the question seems to point towards liver disease, which directly leads to conditions causing pitting edema.
(d) Colon Cancer:
Colon cancer is not typically associated with pitting edema. While advanced cancer can lead to various complications, including fluid imbalances, it is not a primary cause of pitting edema. Edema related to cancer is often more localized and associated with tumor sites or treatment areas.
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