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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?

A.

Palpation of the patient's lymph nodes

B.

Auscultation of the patient's apical heart rate

C.

Palpation of the patient's liver

D.

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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Related Questions

Correct Answer is C

Explanation

Choice A rationale:
Restricting weight-bearing on the affected foot may provide some temporary relief from pain during an acute gout attack. However, it is not a long-term management strategy and can lead to muscle weakness and joint stiffness. It's important to gradually resume weight-bearing activities as tolerated to maintain joint function.

Choice B rationale:
Adequate fluid intake is essential for overall health and can help to flush out uric acid from the body. However, 8 liters per day is an excessive amount of fluid and could lead to electrolyte imbalances and other health problems. A more appropriate recommendation for a client with gout would be to aim for a fluid intake of 2-3 liters per day, unless otherwise advised by a healthcare provider.

Choice C rationale:
Restricting consumption of foods high in purines is a key management strategy for gout. Purines are substances found in certain foods that break down into uric acid in the body. High levels of uric acid can lead to the formation of urate crystals, which deposit in joints and cause inflammation and pain. Examples of foods high in purines include organ meats, red meat, seafood, and some types of beans and lentils.

Choice D rationale:
Calcium supplements have not been shown to be effective in the management of gout. In fact, some studies have suggested that calcium supplements may even increase the risk of gout attacks.

Correct Answer is ["1370"]

Explanation

To calculate the total output for the client, we need to add up all the individual outputs:

  • The client voided 400 mL at 1100.
  • The client voided 350 mL at 1430.
  • The closed chest drainage system increased from 155 mL to 175 mL, which is an increase of 20 mL.
  • The NG tube has 575 mL in the drainage container.
  • The Jackson-Pratt drainage tube has 25 mL.

Adding all these amounts together, the total output that the nurse should record in the medical record is 1370 mL.

Here’s the calculation:

400 mL + 350 mL + (175 mL - 155 mL) + 575 mL + 25 mL = 1370 mL400mL+350mL+(175mL−155mL)+575mL+25mL=1370mL

So, the nurse should record a total output of 1370 mL in the medical record for the client.

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