The nurse is examining a female client who states, she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Recent over-the-counter infection cures.

Nontender, firm lymph nodes.

Number of indoor cats at home.

Amount of daily caffeine consumption.

Answer and Explanation

The Correct Answer is B

A. Recent over-the-counter infection cures. This is less immediately relevant unless directly related to lymph node changes.

B. Nontender, firm lymph nodes. This is the correct choice. Nontender, firm lymph nodes can indicate a more serious underlying condition such as malignancy or chronic infection and require further investigation.

C. Number of indoor cats at home. This might be relevant if there is a concern for cat scratch disease, but it is less critical than the nature of the lymph nodes.

D. Amount of daily caffeine consumption. This is not related to the palpation of lymph nodes and is not immediately relevant to the findings.

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Correct Answer is B

Explanation

A. Rigidity and firmness. This is not typically expected; rigidity and firmness may indicate muscle spasm or guarding.

B. Sharp, severe pain. This is expected with pyelonephritis, as percussion over the inflamed kidney will elicit pain.

C. Rebound tenderness. Rebound tenderness is more indicative of peritoneal irritation rather than pyelonephritis.

D. Audible thud without pain. This is a normal finding; absence of pain does not align with the expected findings in pyelonephritis.

A. Continue with the remainder of the client's physical assessment. B. Ask the client to cough and then auscultate at the site again. C. Report the client's abnormal lung sounds to the healthcare provider. D. Measure the client's oxygen saturation with a pulse oximeter.

Correct Answer is A

Explanation

A. Continue with the remainder of the client's physical assessment. Vesicular breath sounds are normal and expected over the lung bases, so the nurse should continue the assessment.

B. Ask the client to cough and then auscultate at the site again. This action is unnecessary as vesicular breath sounds are normal.

C. Report the client's abnormal lung sounds to the healthcare provider. This is incorrect as vesicular breath sounds are not abnormal.

D. Measure the client's oxygen saturation with a pulse oximeter. There is no indication of abnormal breath sounds or respiratory distress, so this action is unnecessary.

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The nurse is examining a female client who states, she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is B

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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