The nurse is preparing to assess an elderly client. Which of ...

[lilldybug07]

The nurse is preparing to assess an elderly client. Which of these approaches would be most appropriate for the nurse to take when assessing the thyroid gland of this client?
 
  1. Stand in front of the client and palpate the thyroid after telling the client what the procedure is.
   2. Place the client supine and palpate one side of the neck at a time.
   3. Ask the client's permission to touch the neck and then stand behind the client and palpate the thyroid.
   4. Have the client flex the neck forward and palpate the thyroid.

Question 2

The home health care nurse is preparing a care plan for a client admitted with anemia. The client currently lives alone and states, I can't even take a shower without getting winded..
 
  Which of the following would be the priority nursing diagnosis for this client? 1. Activity Intolerance
   2. Anxiety
   3. Hopelessness
   4. Altered Nutrition, Less than Body Requirements

[cat123]

Answer to Question 1

3. Ask the client's permission to touch the neck and then stand behind the client and palpate the thyroid.

Rationale:
In order not to alarm the elderly client, the nurse would ask permission to touch the client and explain the procedure. The thyroid is palpated by standing behind the client and placing the fingers on each side of the trachea below the thyroid, and asking the client to swallow to palpate the right lobe. Repeat the procedure, tilting the neck to the left. The nurse has better access to the thyroid from a posterior approach than from the anterior aspect. Placing the client supine would not permit the nurse to have full access to the neck. Flexing the neck forward if there were a mass could occlude the airway.

Answer to Question 2

1. Activity Intolerance

Rationale:
Activity Intolerance would be a priority diagnosis for this client. While anxiety, hopelessness, and altered nutrition may be appropriate nursing diagnoses for this client, they are not the priority.

[lilldybug07]

Gracias!

[matt95]

TYSM