The practical nurse (PN) is performing a focused assessment on a client with hyperthyroidism. To confirm the presence of exophthalmos, which action should the PN include in the assessment?

Palpating the client's neck gently.

Measuring the client's vital signs.

Compressing the client's pretibial area.

Observing the client's face and eyes.

Answer and Explanation

The Correct Answer is D

Choice A reason: Palpating the client's neck gently is important in assessing thyroid function, as it can help detect the presence of thyroid enlargement or nodules. However, this action does not confirm the presence of exophthalmos, which is characterized by the protrusion of the eyeballs. Neck palpation is useful for evaluating thyroid size and consistency but does not provide information about eye-related symptoms.
Choice B reason: Measuring the client's vital signs, including heart rate, blood pressure, and temperature, is essential in monitoring the overall health and metabolic status of a client with hyperthyroidism. Hyperthyroidism can lead to increased heart rate, elevated blood pressure, and other systemic effects. However, measuring vital signs does not confirm the presence of exophthalmos. While vital signs provide important information about the client's condition, they do not address specific eye symptoms.
Choice C reason: Compressing the client's pretibial area is typically performed to assess for pretibial myxedema, which is another possible manifestation of hyperthyroidism, particularly in Graves' disease. Pretibial myxedema is characterized by thickening and swelling of the skin on the lower legs. However, this action does not confirm the presence of exophthalmos. It is important to assess for both pretibial myxedema and exophthalmos in clients with hyperthyroidism, but they require different examination techniques.
Choice D reason: Observing the client's face and eyes is the correct action to confirm the presence of exophthalmos. Exophthalmos is the abnormal protrusion of the eyeballs and is a common feature of Graves' disease, a type of hyperthyroidism. By carefully examining the client's face and eyes, the practical nurse can look for signs of eye protrusion, lid retraction, and other related symptoms. This focused assessment helps in identifying exophthalmos and determining the extent of the condition, which is essential for appropriate management and treatment.

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Correct Answer is A

Explanation

Choice A reason: Coughing over the catheter site while cleansing the skin is a behavior that indicates the client needs additional teaching. This action can introduce bacteria and other pathogens to the catheter site, increasing the risk of infection. Proper technique should include covering the mouth when coughing and ensuring the area remains as sterile as possible during the cleansing process. Educating the client on the importance of maintaining sterility and preventing contamination is crucial in peritoneal dialysis catheter care.
Choice B reason: Wearing only one sterile glove when cleansing the insertion site may not be ideal, but it does not necessarily indicate a lack of understanding or need for additional teaching. The main concern is ensuring the insertion site is cleaned properly. However, best practice would be to wear two sterile gloves to maintain sterility and reduce the risk of infection.
Choice C reason: Washing hands before opening the 4 by 4 dressing packet is a proper and essential technique in peritoneal dialysis catheter care. This action helps minimize the risk of infection by ensuring that the hands are clean before handling sterile supplies. This behavior does not indicate a need for additional teaching.
Choice D reason: Pouring antiseptic solution and sterile water on sterile dressings is an acceptable practice in peritoneal dialysis catheter care. This step helps disinfect the catheter site and maintain sterility. This behavior does not indicate a need for additional teaching.

A. Apply direct pressure over the area that is bleeding. B. Wipe off the drop of blood with a gauze pad. C. Clean the finger with an alcohol prep pad. D. Apply the drop of blood to the test strip.

Correct Answer is D

Explanation

Choice A reason: Applying direct pressure over the area that is bleeding is a general first aid measure to stop bleeding. However, in the context of obtaining a fingerstick blood sugar, this action is not the immediate next step. The objective of the fingerstick is to obtain a sample of blood for testing blood glucose levels. Applying pressure would stop the flow of blood, making it difficult to obtain a sufficient sample for the test.
Choice B reason: Wiping off the drop of blood with a gauze pad is not recommended after pricking the finger for a blood glucose test. Removing the initial drop of blood could result in the need to squeeze the finger again, potentially causing hemolysis (breaking of blood cells) and leading to an inaccurate reading. It is important to use the initial drop of blood for the test to ensure accurate results.
Choice C reason: Cleaning the finger with an alcohol prep pad before pricking is a standard step to ensure that the area is free from contaminants and to prevent infection. However, doing this after the drop of blood is visible is unnecessary and can interfere with the sample. Alcohol residue can affect the accuracy of the blood glucose reading. Therefore, cleaning should be done prior to pricking, not after the blood is obtained.
Choice D reason: Applying the drop of blood to the test strip is the correct action to take. Once the drop of blood is visible, it should be applied to the test strip immediately to obtain a blood glucose reading. This ensures that the sample is fresh and uncontaminated, providing an accurate measurement of the client's blood sugar levels. This step is essential for effective monitoring and management of diabetes.

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The practical nurse (PN) is performing a focused assessment on a client with hyperthyroidism. To confirm the presence of exophthalmos, which action should the PN include in the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assisting a client who is performing peritoneal dialysis catheter self-care before being discharged home. Which behavior indicates that the client needs additional teaching?

Correct Answer is A

Explanation

When obtaining a fingerstick blood sugar, the practical nurse (PN) uses the lancet to prick the client's finger. After observing that a drop of blood is visible on the finger, which action should the PN take?

Correct Answer is D

Explanation

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