During the assessment, the nurse notices areas of the throat that are raw and inflamed. Which technique should the nurse use to assess further?

Inspection

Palpation

Percussion

Auscultation

Answer and Explanation

The Correct Answer is A

Choice A reason: Inspection is the primary technique to further assess a raw, inflamed throat, allowing visualization of color, swelling, or lesions. This non-invasive method is appropriate, making it the correct choice for throat assessment.

Choice B reason: Palpation is inappropriate for a raw throat, as it may cause pain or spread infection. Inspection visually evaluates inflammation, so this is incorrect for further assessment.

Choice C reason: Percussion is used for chest or abdomen, not throat assessment. Visual inspection is needed for inflamed throat tissue, so this is incorrect for the technique required.

Choice D reason: Auscultation is for sounds (e.g., lungs), not visual throat changes. Inspection allows direct observation of inflammation, so this is incorrect for assessing throat condition.

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Correct Answer is B

Explanation

Choice A reason: Reading handheld print tests reading near vision, not standard visual acuity, which requires distance assessment. The Snellen chart at 20 feet is the standard, so this is incorrect for acuity testing.

Choice B reason: The Snellen chart, positioned 20 feet away, is the standard method for assessing visual acuity in adolescents, providing a reliable measure of distance vision. This is the correct procedure for the nurse.

Choice C reason: The confrontation test assesses peripheral vision, not central acuity. The Snellen chart measures sharpness of vision, so this is incorrect for the purpose of visual acuity assessment.

Choice D reason: Reading newsprint at 12–14 inches tests near vision, not distance acuity, which is the standard for screening. The Snellen chart at 20 feet is appropriate, so this is incorrect.

A. Malnutrition B. Overhydration C. Severe edema D. Severe dehydration

Correct Answer is D

Explanation

Choice A reason: Malnutrition may cause skin changes like dryness or thinning but does not typically cause tenting. Tenting reflects loss of skin elasticity due to fluid deficit, not primarily nutritional deficiency, making this an incorrect interpretation of the finding.

Choice B reason: Overhydration causes skin edema, leading to pitting or swelling, not tenting. Tenting occurs when skin lacks moisture and elasticity, which is the opposite of fluid excess, making this an incorrect interpretation of the observed skin turgor.

Choice C reason: Severe edema results in swollen, pitting skin due to fluid retention, not tenting. Tenting indicates a lack of interstitial fluid, as seen in dehydration, making this an incorrect interpretation of the skin turgor finding.

Choice D reason: Skin tenting, where skin slowly returns to its normal position after pinching, indicates severe dehydration. This occurs due to reduced interstitial fluid and loss of skin elasticity, commonly seen in significant fluid loss, making this the correct interpretation.

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During the assessment, the nurse notices areas of the throat that are raw and inflamed. Which technique should the nurse use to assess further?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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