A nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

Palpation of the patient's lymph nodes

Auscultation of the patient's apical heart rate

Palpation of the patient's liver

Percussion of the patient's abdomen

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Lymph nodes are small, bean-shaped structures that play a crucial role in the immune system. They filter lymph fluid, which carries white blood cells and other immune cells throughout the body.
When the body is fighting an infection or other immune challenge, lymph nodes often swell and become tender. This is because they are actively working to filter out pathogens and activate immune cells.
Palpation of the lymph nodes can provide valuable information about the patient's immune function. The nurse can assess for enlargement, tenderness, and mobility of the lymph nodes.
Lymph node assessment is a non-invasive, painless procedure that can be performed quickly and easily.
Choice B rationale:
Auscultation of the apical heart rate is important for assessing cardiovascular function, but it does not directly assess immune function.
While heart rate can be indirectly affected by certain immune conditions (e.g., fever), it is not a primary indicator of immune system activity.
Choice C rationale:
Palpation of the liver can provide information about liver size and consistency, but it does not directly assess immune function.
The liver plays a role in immune function by producing proteins that help fight infection, but its size and consistency do not necessarily reflect its immune activity.
Choice D rationale:
Percussion of the abdomen can be used to assess the size and location of abdominal organs, but it does not directly assess immune function.
While certain immune conditions may involve abdominal organs (e.g., splenomegaly), percussion is not a primary method for assessing immune function.

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Correct Answer is C

Explanation

Choice A rationale:
Holding the client's arms and legs from moving during a seizure can actually cause injury to the client or the nurse. The forceful muscle contractions that occur during a seizure can cause bones to break or joints to dislocate. Additionally, trying to restrain the client can increase their agitation and make the seizure worse.

Choice B rationale:
Placing the client back in bed during a seizure is not safe. The client could fall out of bed and injure themselves. It is also important to allow the client to have space to move freely during the seizure to prevent injury.

Choice C rationale:

Placing the client on their side is the safest position for a client who is having a seizure. This position helps to protect the airway and prevent aspiration. It also allows any fluids or secretions to drain out of the mouth, which can help prevent choking.

Choice D rationale:
Inserting a tongue blade into the client's mouth during a seizure is not recommended. It is a common misconception that people can swallow their tongue during a seizure. This is not possible. Inserting a tongue blade can actually cause more harm than good. It can break teeth, damage the mouth, or even block the airway.

A. A 39-year-old female hospitalized with anorexia nervosa and has a BMI of 14 B. A 56-year-old male who is consuming foods low in purines C. A 5-year-old male with a BMI of 24 who reports a vegetarian diet D. A female with ulcerative colitis .

Correct Answer is A

Explanation

Anorexia nervosa is a condition characterized by severe weight loss and malnutrition. People with anorexia nervosa are often deficient in nutrients, including purines. Purines are broken down in the body to produce uric acid. When there is an excess of purines in the body, uric acid levels can rise, leading to gout.

Choice B is incorrect. While consuming foods low in purines can help to prevent gout attacks, it is not a risk factor for developing gout.
Choice C is incorrect. Children are not at risk for developing gout. Gout is more common in adults, especially men.
Choice D is incorrect. Ulcerative colitis is an inflammatory bowel disease that is not associated with an increased risk of gout.

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A nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

The nurse is caring for a group of patients on a medical surgical unit. Which of the following patients is at most risk for developing gout?

Correct Answer is A

Explanation

The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

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