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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Naming the past four presidents tests remote memory, as it involves recalling historical facts learned years ago. Recent memory involves events from hours or days, so this question does not assess the patient’s short-term memory capacity effectively.
Choice B reason: Recalling children’s names typically involves long-term memory, as these are familiar, well-established facts. While personal, this information is not recent and does not evaluate the patient’s ability to retain new information, making it unsuitable for recent memory assessment.
Choice C reason: A mother’s maiden name is a long-term memory fact, often memorized years ago. It does not test recent memory, which focuses on newly acquired information, making this question inappropriate for assessing short-term memory in the elderly patient.
Choice D reason: Asking about breakfast this morning tests recent memory, as it involves recalling an event from hours ago. This is ideal for assessing short-term memory function in older adults, as it evaluates the ability to retain and recall new information accurately.
Correct Answer is D
Explanation
Choice A reason: Frequency refers to frequent urination, not difficulty starting the stream. Hesitancy describes the specific symptom of delayed urine flow, often in prostate issues, so this is incorrect for documentation.
Choice B reason: Urgency is the sudden need to urinate, not trouble initiating the stream. Hesitancy captures the patient patient’s symptom of starting urination, making this incorrect for the term used.
Choice C reason: Spray is not a medical term for urinary symptoms; it’s irrelevant to starting difficulty. Hesitancy is the precise term for this issue, so this is incorrect for documentation purposes.
Choice D reason: Hesitancy is the term used for difficulty initiating the urine stream, often due to obstruction like benign prostatic hyperplasia. This matches the patient’s symptom, making it the correct term for documentation.
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