A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

Hypothyroidism

Gingivitis

Aphthous ulcers

Dysphagia

Answer and Explanation

The Correct Answer is A

Choice a reason:
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. This can lead to a variety of symptoms, including hoarseness, fatigue, and weight gain. The hoarseness can be due to the effect of hormone deficiency on the vocal cords, while fatigue and weight gain are common due to the slowed metabolism associated with hypothyroidism.

Choice b reason:
Gingivitis is inflammation of the gums and does not typically cause hoarseness, fatigue, or weight gain. It is more commonly associated with symptoms like red, swollen gums and bleeding during brushing or flossing.

Choice c reason:
Aphthous ulcers, also known as canker sores, are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. While they can be painful and cause difficulty with eating and speaking, they do not cause systemic symptoms such as hoarseness, fatigue, or weight gain.

Choice d reason:
Dysphagia, or difficulty swallowing, can lead to hoarseness if there is an associated throat disorder. However, it is not typically associated with systemic symptoms like fatigue and weight gain unless it is part of a broader condition that affects the body's metabolism or energy levels.

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Correct Answer is C

Explanation

Choice a reason:
Assisting the client to a sitting position is not the best action to ensure that bowel sounds can be heard. For abdominal auscultation, the patient should be lying down in a supine position to relax the abdominal muscles, which facilitates the hearing of bowel sounds.

Choice b reason:
Percussion of the abdomen before auscultation is not recommended as the best initial action. Percussion can stimulate bowel motility, which may alter the natural bowel sounds that the nurse is attempting to assess.

Choice c reason:
Reducing all environmental noise is the best action to ensure that bowel sounds can be heard clearly. Environmental noise can mask the subtle sounds of bowel motility, and minimizing distractions allows for a more accurate assessment of bowel activity.

Choice d reason:
Palpating the region before auscultating is not the best action because palpation can also stimulate bowel motility and potentially alter the bowel sounds. Auscultation should be performed before palpation during the abdominal examination to avoid this issue.

A. In front of the ear. B. In the midline, a few centimeters behind the tip of the mandible. C. Superficial to the sternomastoid. D. At the angle of the mandible.

Correct Answer is B

Explanation

Choice A reason:

Palpating in front of the ear would assess the preauricular lymph nodes, not the submental lymph nodes. The preauricular nodes are located just in front of the ears and are typically examined when there is an infection or inflammation in the eyes, ears, or scalp.

Choice B reason:

The submental lymph nodes are located in the midline, just under the chin, behind the bony prominence of the mandible. This is the correct area for palpation when assessing the submental lymph nodes. These nodes drain the lower lip, the floor of the mouth, the tip of the tongue, and the incisors, and they can become enlarged due to infections or malignancies in these areas.

Choice C reason:

Palpating superficial to the sternomastoid would assess the cervical lymph nodes, specifically the anterior cervical nodes, which are not the submental lymph nodes. The sternomastoid muscle is a landmark for several lymph node groups in the neck, but not for the submental group.

Choice D reason:

Palpating at the angle of the mandible would assess the submandibular lymph nodes, not the submental lymph nodes. The submandibular nodes are located beneath the jawline and can become enlarged due to infections or malignancies in the mouth, throat, and salivary glands.

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A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse working in an outpatient GI clinic is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

The nurse knows the importance of assessing vital signs is to:

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