During an admission assessment of a client, the nurse palpates enlarged axillary lymph nodes. Which question should the nurse ask the client related to this finding?
Do you have a history of cardiac disease?
Have you had a recent infection?
Are you having any shortness of breath?
Have you had surgery on your neck?
The Correct Answer is B
Choice A reason: A history of cardiac disease is not directly related to enlarged axillary lymph nodes. Cardiac disease may affect the heart, blood vessels, and circulation, but not the lymphatic system. ¹
Choice B reason: A recent infection is a possible cause of enlarged axillary lymph nodes. Lymph nodes are part of the immune system and they swell when they are fighting an infection. ² The nurse should ask the client about any signs or symptoms of infection, such as fever, sore throat, or skin rash.
Choice C reason: Shortness of breath is not directly related to enlarged axillary lymph nodes. Shortness of breath may indicate a respiratory problem, such as asthma, bronchitis, or pneumonia. ³ However, these conditions do not usually affect the lymph nodes in the armpit area.
Choice D reason: Surgery on the neck is not directly related to enlarged axillary lymph nodes. Surgery on the neck may affect the lymph nodes in the neck or the collarbone area, but not the lymph nodes in the armpit area. The nurse should ask the client about any history of surgery or trauma to the lymph nodes or the surrounding tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Total cholesterol is not the best indicator of the effectiveness of simvastatin, a drug that lowers cholesterol levels and reduces the risk of cardiovascular disease. ¹ Total cholesterol includes both LDL and HDL (high density lipoprotein), which have opposite effects on the heart and blood vessels. ² The normal range of total cholesterol for adults is less than 200 mg/dL, but this does not reflect the balance between LDL and HDL.
Choice B reason: Blood pressure is not directly related to the effectiveness of simvastatin, although high blood pressure and high cholesterol are both risk factors for cardiovascular disease. ³ Simvastatin does not lower blood pressure, but it may prevent or slow down the development of atherosclerosis, which is the narrowing and hardening of the arteries due to plaque buildup. ¹ The normal range of blood pressure for adults is less than 120/80 mmHg.
Choice C reason: Serum triglycerides are another type of fat in the blood that can contribute to cardiovascular disease. ² Simvastatin can lower triglyceride levels, but this is not its main effect. ¹ The normal range of serum triglycerides for adults is less than 150 mg/dL.
Choice D reason: LDL is the main target of simvastatin therapy, as it is the "bad" cholesterol that can cause plaque buildup and damage the arteries. ¹ Simvastatin works by inhibiting an enzyme that produces LDL in the liver. The optimal level of LDL for adults is less than 100 mg/dL, and even lower for those with high risk of cardiovascular disease. ² A LDL level of 90 mg/dL indicates that the client's current dose of simvastatin has been effective.
Correct Answer is C
Explanation
Choice A reason: Having a urinary output of greater than 30 mL per hour for 24 hours is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of fluid volume excess or renal impairment, which are not the case for this client.
Choice B reason: Discussing which lifestyle modifications will be necessary to maintain health is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of knowledge deficit or risk for recurrence, which are not the priority for this client.
Choice C reason: Expressing no complaints of chest discomfort or shortness of breath is the most appropriate outcome for the problem of impaired tissue perfusion. This outcome indicates that the client's cardiac output and oxygen delivery are adequate and that the interventions are effective.
Choice D reason: Having clear breath sounds bilaterally upon auscultation is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of impaired gas exchange or pulmonary congestion, which are not the case for this client.
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