The nurse is conducting an endocrine assessment on a patient with cognitive impairment. Which nursing action is indicated?
1. Defer palpation of the thyroid.
2. Perform the palpation from in front of the patient.
3. Use standard palpation technique from behind the patient.
4. Have the caretaker hold the patient's head still during the exam.
2
Rationale 1: Thyroid palpation is an integral part of endocrine assessment and should not be deferred.
Rationale 2: The patient is likely to be calmer if the nurse is in sight.
Rationale 3: If the patient has cognitive impairment, approaching from behind and placing hands on the neck may cause anxiety.
Rationale 4: The combination of having a stranger's hands on the neck and being held by the caretaker may cause extreme anxiety in this patient.
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