When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?
to prevent further dehydration
to assist the client to feel more comfortable
to observe the movement of the thyroid gland
to promote the nurse-client relationship
The Correct Answer is C
A. To prevent further dehydration:
While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.
B. To assist the client to feel more comfortable:
Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.
C. To observe the movement of the thyroid gland:
Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.
D. To promote the nurse-client relationship:
Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Mucous Membranes:
In clients with dark skin, mucous membranes such as the lips, tongue, and gums are the best sites to assess for cyanosis. These areas have less pigmentation and are more vascular, allowing for a more accurate evaluation of oxygenation and the presence of cyanosis.
B. Dorsal surface of the hand:
The dorsal surface of the hand can be used to assess for cyanosis in lighter-skinned individuals, but it is less reliable in dark-skinned clients due to the higher melanin content, which can obscure the bluish tint indicative of cyanosis.
C. Dorsal surface of the foot:
Similar to the dorsal surface of the hand, the dorsal surface of the foot is not an ideal site for assessing cyanosis in clients with dark skin. The presence of melanin can make it difficult to detect changes in skin color.
D. Pinnae of the ears:
The pinnae of the ears are also not the best sites for assessing cyanosis in dark-skinned clients. These areas can be highly pigmented, which can mask the bluish discoloration associated with cyanosis. The mucous membranes remain the most reliable site for this assessment.
Correct Answer is D
Explanation
Stage I: Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin. There is no break in the skin, but it may appear red and warm to the touch. It is considered the mildest form of pressure injury, signaling the beginning of potential skin damage.
B) Stage III: Stage III pressure ulcers involve full-thickness skin loss. This means that the damage extends through the dermis into the subcutaneous tissue. There may be visible fat, but bone, tendon, and muscle are not exposed. These ulcers are deeper and more serious than the scenario described.
C) Stage IV: Stage IV pressure ulcers are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. The presence of slough or eschar may be present on some parts of the wound bed, and these ulcers are deep, often with extensive damage and infection.
D) Stage II: Stage II pressure ulcers are characterized by partial-thickness skin loss involving the epidermis and/or dermis. They present as shallow, open ulcers with a red-pink wound bed, without slough. They may also appear as intact or open/ruptured serum-filled blisters, which matches the description given in the scenario. This stage represents a more significant injury than Stage I but does not extend into the deeper layers of skin and tissue as in Stage III and IV.
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