The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

Size

Consistency

Shape

Color

Answer and Explanation

The Correct Answer is D

A) Size:

When assessing lymph nodes, noting the size is crucial as enlarged lymph nodes can indicate infection, inflammation, or malignancy. Size helps in determining the extent and severity of the underlying condition.

B) Consistency:

The consistency of lymph nodes (whether they are hard, rubbery, or soft) provides important diagnostic information. For instance, hard lymph nodes may suggest malignancy, while soft nodes might indicate an infection.

C) Shape:

Recording the shape of lymph nodes is essential in the assessment process. Regular, oval, or round shapes can be normal, while irregularly shaped nodes might be concerning and warrant further investigation.

D) Color:

Color is not typically assessed or noted when examining lymph nodes. Lymph nodes are internal structures, and their color cannot be directly observed without invasive procedures. The focus is usually on palpable characteristics like size, consistency, and shape.

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Correct Answer is A

Explanation

A) Eye turning inward:

Esotropia is a condition where one or both eyes turn inward, leading to misalignment. This inward turning can cause double vision, depth perception issues, and sometimes amblyopia (lazy eye) if not treated early. This is the primary characteristic that defines esotropia.

B) Eye malalignment:

While eye malalignment is a general term that can describe conditions like esotropia, exotropia, or hypertropia, it does not specify the direction of the misalignment. Esotropia specifically refers to inward turning of the eye, which is a more precise description of the condition.

C) Eye oscillating:

Eye oscillation refers to nystagmus, which is a condition characterized by repetitive, uncontrolled movements of the eyes, often resulting in reduced vision. Nystagmus is not related to esotropia, which involves inward turning rather than oscillation.

D) Eye turning outward:

Eye turning outward is known as exotropia, which is the opposite of esotropia. Exotropia involves the eyes turning away from the nose, whereas esotropia involves the eyes turning towards the nose. These are distinct conditions with different clinical presentations.

A. Dehydration B. Hypervolemia C. Properly Hydrated D. Infection

Correct Answer is A

Explanation

A) Dehydration:

When the skin remains tented and returns to its normal position slowly after being pinched, it indicates decreased skin turgor, which is a clinical sign of dehydration. Dehydration can occur due to fluid loss from sweating during vigorous physical activity like a beach tournament.

B) Hypervolemia:

Hypervolemia refers to excess fluid volume in the body, which would typically manifest with signs such as peripheral edema or jugular vein distention rather than decreased skin turgor.

C) Properly Hydrated:

Properly hydrated individuals would have normal skin turgor, where the skin returns promptly to its normal position after being pinched.

D) Infection:

Skin tenting is not a specific sign of infection. Infection would typically present with localized signs such as redness, warmth, swelling, and possibly systemic signs like fever.

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The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

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Naxlex Comprehensive Predictor Exams

Which of the following would a nurse expect to assess in a client with esotropia?

Correct Answer is A

Explanation

During your physical examination of a 29-year-old professional volley ball player who recently completed a beach tournament, you gently pinch the skin on the chest area. The skin remains in a "tent" shape and slowly returns to its normal position. This is a sign of

Correct Answer is A

Explanation

During an assessment the nurse performs the action shown in this image. What is the purpose of this action?

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

A nurse measures a patient height and weight and calculate his BMI. Patient BMI is 37. Classify according to this BMI results?

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?