The nurse palpates a swollen inguinal lymph node. Which assessment should the nurse perform next?

Assess the forearm and hand for infection

Assess the lower extremities

Assess the dorsalis pedis pulses

None of the above

Answer and Explanation

The Correct Answer is B

A.   Assess the forearm and hand for infection would be relevant if the swollen lymph node were in the upper extremity, but the inguinal node would be more associated with a lower extremity infection.
B.   Assess the lower extremities is the correct next step since the inguinal lymph nodes drain the lower body, including the legs and genital area.
C.   Assess the dorsalis pedis pulses is not the next step, though it may be important if vascular concerns are suspected.
D.   None of the above is incorrect because assessing the lower extremities is the next logical step.

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Correct Answer is ["A","D","E","G"]

Explanation

A. Client's blood pressure is relevant as it can help correlate the murmur with potential cardiac conditions.
B. Client's weight is not directly related to documenting a heart murmur.
C. Client's respiratory rate is also not relevant to the murmur documentation unless respiratory symptoms are present.
D. Intensity of the murmur is important to document, as it helps assess the severity.
E. Location of the murmur is important for identifying which valve or area of the heart is involved.
F. Client's temperature is not directly related to documenting a heart murmur.
G. Timing of the murmur helps in identifying whether it occurs during systole or diastole, aiding in diagnosis.

A. Xerostomia B. Rhinorrhea C. Dysphagia D. Epistaxis

Correct Answer is C

Explanation

A. Xerostomia (dry mouth) is common in some conditions but not typically associated with a stroke.
B. Rhinorrhea (runny nose) is not a typical finding related to stroke.
C. Dysphagia (difficulty swallowing) is a common issue for patients after a stroke, especially if the stroke affects the areas of the brain responsible for swallowing.
D. Epistaxis (nosebleed) is not a direct consequence of a stroke. The nurse should be more concerned with symptoms related to swallowing, speech, and motor function, such as dysphagia.

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The nurse palpates a swollen inguinal lymph node. Which assessment should the nurse perform next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

Correct Answer is ["A","D","E","G"]

Explanation

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

Correct Answer is C

Explanation

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