The nurse is preparing to assess an adult client. The focus of the exam will be on the head and neck. Which statement by the nurse is appropriate when preparing the client for the thyroid examination?
1. "Please lie down while I assess your thyroid gland."
2. "When I assess your thyroid gland, you can expect to feel strong pressure."
3. "I will stand behind you while palpating your thyroid gland."
4. "Please chew this mint so that I can assess your thyroid gland."
Correct Answer: 3
The nurse will stand behind the client while palpating the thyroid gland. The client is either asked to sit on the exam table or stand up during a thyroid gland assessment. Lying down will not allow the nurse to complete an accurate assessment of the thyroid gland. The nurse will apply light pressure, not strong pressure, during thyroid gland palpation. The nurse would ask the client to swallow water to distinguish the thyroid from other structures. Chewing a mint would be appropriate to assess certain cranial nerves.
You might also like to view...
Which of the following is an example of assessment data?
a. Altered nutrition b. Resident will walk 100 feet each afternoon c. Resident complaining of difficulty swallowing d. Monitor the resident's oral intake
A student nurse asks how the nursing process is different from critical thinking. The best reply by the faculty member is that the nursing process is
a. a tool for applying critical thinking to patient care. b. merely the way nurses articulate patient care needs. c. the only way to use critical thinking for best outcomes. d. the same thing as critical thinking divided into steps.
What should patients taking antidiuretic hormone (ADH) be monitored frequently for?
a. Increase in urination b. Urinary acidity c. Dehydration d. Urinary alkalinity
Which assessment findings would alert the nurse of an impending wound dehiscence on a patient with an abdominal incision on postoperative day 5?
A) Incision edges are well-approximated. B) Abdominal dressing has purulent drainage. C) Incision has a healing ridge. D) Incision is pink with scant serous drainage.