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 D
Explanation
A) Size:
When assessing lymph nodes, noting the size is crucial as enlarged lymph nodes can indicate infection, inflammation, or malignancy. Size helps in determining the extent and severity of the underlying condition.
B) Consistency:
The consistency of lymph nodes (whether they are hard, rubbery, or soft) provides important diagnostic information. For instance, hard lymph nodes may suggest malignancy, while soft nodes might indicate an infection.
C) Shape:
Recording the shape of lymph nodes is essential in the assessment process. Regular, oval, or round shapes can be normal, while irregularly shaped nodes might be concerning and warrant further investigation.
D) Color:
Color is not typically assessed or noted when examining lymph nodes. Lymph nodes are internal structures, and their color cannot be directly observed without invasive procedures. The focus is usually on palpable characteristics like size, consistency, and shape.
Correct Answer is D
Explanation
A) Dysphagia:
Dysphagia refers to difficulty swallowing and is typically associated with conditions affecting the esophagus or neuromuscular function. While it can coexist with other symptoms, it does not directly explain hoarseness, fatigue, and weight gain as hypothyroidism does.
B) Gingivitis:
Gingivitis is an inflammation of the gums due to plaque buildup. It primarily affects oral health, causing redness, swelling, and bleeding of the gums. It is not associated with systemic symptoms like hoarseness, fatigue, or weight gain.
C) Aphthous ulcers:
Aphthous ulcers, also known as canker sores, are small, painful lesions that develop in the mouth. They are typically caused by stress, minor injury, or certain foods. These ulcers do not explain the systemic symptoms described by the client.
D) Hypothyroidism:
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. Symptoms include hoarseness, fatigue, weight gain, dry skin, and cold intolerance. The combination of these symptoms in the client's history makes hypothyroidism the most likely cause.
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