The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Wash hands
Provide patient privacy
Obtain a provider healthcare order
Position the client comfortably on the sturdy examination table
Explain the procedure to the client
Correct Answer : A,B,D,E
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
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Correct Answer is ["A","B","C","D"]
Explanation
A. Cold intolerance: Patients with hypothyroidism often have difficulty regulating body temperature, leading to a heightened sensitivity to cold.
B. Depression: Hypothyroidism can affect mood and cognitive function, often leading to symptoms of depression.
C. Weakness and fatigue: Low thyroid hormone levels can cause significant fatigue and muscle weakness due to a slower metabolism.
D. Constipation: A slowed metabolism can also affect gastrointestinal motility, resulting in constipation.
E. Mental alertness: This is typically not expected in hypothyroid patients. In fact, they may experience cognitive impairments, memory issues, or slowed thinking rather than mental alertness.
Correct Answer is ["B","C","D"]
Explanation
A. Pale yellow urine is typically associated with good hydration; dehydration would likely result in darker urine.
B. Poor skin turgor is a classic sign of dehydration, indicating a lack of adequate fluid in the tissues.
C. Hypotension (low blood pressure) can occur with dehydration due to decreased blood volume.
D. Flat neck veins may indicate a decrease in venous return due to low blood volume associated with dehydration.
E. Bradycardia (slow heart rate) is not typically a finding associated with dehydration; instead, dehydration often leads to tachycardia (increased heart rate) as the body attempts to compensate for low blood volume.