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 A

Explanation

A. Note the client's responses during the initial interview. This allows the nurse to observe the client's natural speech patterns in a conversational context, which is a realistic and comprehensive way to assess speech.

B. Ask the client to complete a common proverb or saying. This approach assesses the client's understanding and familiarity with language but may not comprehensively evaluate speech patterns.

C. Listen while the client reads items listed on the menu. This tests reading ability and articulation but may not reflect the client’s natural speech patterns during conversation.

D. Have the client repeat a phrase containing alliteration. This can help assess speech articulation and clarity but is not comprehensive for evaluating overall speech patterns.

A. 2+ pitting edema of ankles bilaterally. B. Capillary refill both feet greater than 3 seconds. C. Pedal pulses weak and thready. D. Positive Homan's sign bilaterally.

Correct Answer is A

Explanation

A. 2+ pitting edema of ankles bilaterally. This is the best choice because it directly indicates fluid retention and swelling in the feet.

B. Capillary refill both feet greater than 3 seconds. Delayed capillary refill suggests poor circulation but does not directly confirm swelling.

C. Pedal pulses weak and thready. Weak pulses indicate poor circulation but do not confirm swelling.

D. Positive Homan's sign bilaterally. Positive Homan's sign can indicate deep vein thrombosis but does not directly relate to chronic swelling.

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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

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Correct Answer is A

Explanation

Which assessment finding supports the client statement, "My feet swell all the time?"

Correct Answer is A

Explanation

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

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