The nurse is examining a female client who states she has no complaints and 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.

Amount of daily caffeine consumption.

Number of indoor cats at home.

Nontender, firm lymph nodes.

Answer and Explanation

The Correct Answer is D

A. Information about over-the-counter treatments might be relevant but is less critical than the physical findings.
B. Daily caffeine consumption is unlikely to be directly related to the presence of enlarged lymph nodes.
C. Having indoor cats might be relevant if there was suspicion of an infection like toxoplasmosis, but this is not the most immediate concern.
D. Nontender, firm lymph nodes, especially when persistent and not related to a known infection, can be concerning and may indicate malignancy or other serious conditions. This finding should be promptly reported to the healthcare provider for further investigation.

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Correct Answer is D

Explanation

A. Asking the client to follow a three-step task assesses complex functioning and executive skills, which is important but not the most immediate way to evaluate recent memory.
B. Repeating a series of unrelated numbers assesses short-term memory and attention span but does not specifically evaluate recent memory related to daily activities.
C. Asking about the year the client married his wife assesses long-term memory rather than recent memory. Long-term memory is often better preserved than recent memory in many cases of cognitive decline.
D. Asking the client to recall what he ate for breakfast assesses recent memory and is relevant to evaluating the type of memory loss described. Recent memory loss can impact the ability to remember recent events and activities.

A. Rebound tenderness B. Sharp, severe pain C. Audible thud without pain D. Rigidity and firmness

Correct Answer is B

Explanation

A. Rebound tenderness is typically associated with peritoneal irritation and is not expected in pyelonephritis. It is more commonly observed in conditions like appendicitis or peritonitis.
B. Sharp, severe pain upon percussion of the costovertebral angle (CVA) is a hallmark sign of pyelonephritis, indicating inflammation or infection in the kidneys. This response, known as CVA tenderness, is a key diagnostic indicator of this condition.
C. An audible thud without pain would be considered a normal finding and does not suggest the presence of pyelonephritis or other kidney-related issues. The absence of pain would likely rule out significant kidney inflammation.
D. Rigidity and firmness are typically associated with muscle guarding or abdominal wall tension rather than kidney involvement. This finding would not be expected in the context of pyelonephritis.

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The nurse is examining a female client who states she has no complaints and 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?

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Naxlex Comprehensive Predictor Exams

When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

Correct Answer is D

Explanation

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

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