The nurse performs the action shown in this image during the assessment of a client. What is the nurse assessing?
Intercostal spaces
Lymph nodes
Skin Turgor
Carotid Pulse
The Correct Answer is C
A) Intercostal spaces:
Assessing intercostal spaces typically involves palpating or inspecting the area between the ribs to check for abnormalities such as retractions or tenderness, usually conducted with the client sitting or standing.
B) Lymph nodes:
Palpation of lymph nodes, such as in the cervical region, involves using fingertips to gently feel for enlarged or tender nodes. This examination focuses on areas like the neck, underarms, and groin.
C) Skin Turgor:
The image depicts a nurse pinching the skin, likely on the chest or forearm, which is a common method to assess skin turgor. Skin turgor evaluation helps determine hydration status; if the skin remains tented and returns slowly to its original position, it indicates dehydration.
D) Carotid Pulse:
Assessing the carotid pulse involves palpating the carotid artery along the side of the neck to evaluate the strength and rhythm of the pulse. This is typically done using the pads of the fingers, not by pinching the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The Body Mass Index (BMI) is calculated using the formula:
BMI = weight(kg) / height(m)2
First, we need to convert the height from feet and inches to meters.
There are approximately 0.3048 meters in a foot and 0.0254 meters in an inch.
So, 5 feet 5 inches is approximately 1.65 meters.
Substituting the given values into the formula:
BMI = 60 / (1.65)2
This gives us a BMI of approximately 22 when rounded to the nearest whole number.
Therefore, the correct answer is 22 BMI.
Correct Answer is A
Explanation
A) Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens: Adolescents are particularly susceptible to TBIs due to their frequent involvement in contact sports like football, soccer, and hockey, as well as risky behaviors associated with driving. These activities are leading causes of TBIs in this age group, making education on safety measures and proper use of protective equipment essential in prevention efforts.
B) Females have twice the risk that males do: This statement is incorrect. In reality, males are more likely to sustain TBIs than females, especially in adolescence. The higher risk in males is largely due to their greater participation in high-impact sports and higher likelihood of being involved in motor vehicle accidents.
C) Falls occur more frequently in the younger population: Although falls are a significant cause of TBIs in young children and older adults, they are not the primary cause in adolescents. Teens are more likely to sustain TBIs from sports injuries and car accidents, making these areas more relevant for preventive education.
D) Most firearm incidents are accidental: While firearm-related TBIs can occur, they are not as common in the adolescent population compared to injuries from sports and motor vehicle accidents. Prevention efforts should focus more on the activities that pose the highest risk for this age group.
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