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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Protecting the airway is the highest priority during a tonic-clonic seizure. Tonic-clonic seizures involve intense muscle contractions, which can lead to biting the tongue, aspiration of secretions, or even respiratory arrest if the airway is obstructed. Turning the client's head to the side helps to maintain a clear airway and prevent these complications.
It is essential to act quickly to prevent injury and ensure adequate oxygenation. Delaying airway management could have serious consequences.
Choice B rationale:
Checking motor strength is not a priority during the active phase of a seizure. It is more important to focus on protecting the airway and preventing injury.
Motor strength can be assessed after the seizure has subsided.
Choice C rationale:
Loosening clothing around the waist may be helpful to promote comfort and breathing, but it is not the first priority. It is more important to address the airway and prevent aspiration.
Choice D rationale:
Documenting the time the seizure began is important for accurate record-keeping and assessment of seizure patterns, but it is not the first priority in the immediate management of the seizure. Documentation can be done after the client's airway and safety are ensured.
Correct Answer is A
Explanation
Rationale for Choice A:
Tachypnea and restlessness are common signs of respiratory distress, which is a potential complication of pneumonia. These signs indicate that the client's oxygenation may be compromised and require immediate attention.
Rationale for Choice B:
Weight loss of 1 pound since yesterday is a non-specific finding and could be due to a variety of factors, including poor appetite, dehydration, or muscle wasting. While weight loss can be a symptom of HIV infection, it is not an acute sign that requires immediate prioritization in this case.
Rationale for Choice C:
Frequent loose stools can be a symptom of HIV infection or a side effect of certain medications. However, it is not an acute sign that requires immediate prioritization in this case, especially in the context of the client's respiratory distress.
Rationale for Choice D:
An oral temperature of 100°F is a low-grade fever and is not a specific indicator of any serious condition. While fever can be a symptom of pneumonia, it is not the most concerning finding in this case.
Therefore, based on the client's presenting symptoms, tachypnea and restlessness are the most concerning findings and should be prioritized by the nurse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today