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A nurse is caring for a patient in the endocrinologist outpatient clinic.

Exhibits

When completing the assessment at 0810, which of the findings listed below would require a follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 100.5° F

Heart rate 105/min

Respiratory rate 18/min

The client is 34 years of age. States she has a bowel movement after every meal, heat intolerance, and nervousness. The client has lost 20 pounds in the last month without dieting or a change in physical activity. She exercises 4-5 times per week for 45 minutes at a time. States at times during exercise, she experiences irregular heartbeat.

Axillary temperature 100.5° F

Heart rate 105/min

States she has a bowel movement after every meal

heat intolerance, and nervousness

nervousness

The client has lost 20 pounds in the last month without dieting or a change in physical activity

she experiences irregular heartbeat

States at times during exercise

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

The increase in axillary temperature to 100.5° F is significant and could indicate an infection or other inflammatory process. The heart rate has increased to 105/min, which, along with the reported symptoms of heat intolerance, nervousness, and irregular heartbeat during exercise, may suggest an endocrine disorder such as hyperthyroidism. The significant weight loss of 20 pounds in a month without changes in diet or physical activity is also concerning and warrants further investigation. The patient's history of having a bowel movement after every meal could be related to the reported diarrhea and should be explored further.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. A well-defined mass is typically benign, while malignant tumors are often irregular and less defined.

B. Nipple retraction or dimpling can be a sign of a malignant tumor because cancer can cause changes in the breast's structure.

C. Stretch marks are not related to malignancy and are often a result of changes in skin elasticity.

D. Tenderness of the breast is more commonly associated with benign conditions, such as fibrocystic changes, rather than malignancy.

A. Heart murmurs (S3, S4) B. Breath sounds C. Normal heart (S1,S2) D. Bowel sounds

Correct Answer is A

Explanation

A. The bell of the stethoscope is used to detect low-pitched sounds such as heart murmurs (S3 and S4).

B. Breath sounds are typically auscultated using the diaphragm of the stethoscope.

C. Normal heart sounds (S1, S2) are best heard using the diaphragm of the stethoscope.

D. Bowel sounds are auscultated using the diaphragm, not the bell.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a physical examination of a client's breast, which finding would the nurse recognize as a possible indication of a malignant tumor?

Correct Answer is B

Explanation

The nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Correct Answer is A

Explanation

The nurse is developing a plan of care for a client who will be admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis (DVT) of the right leg. What should be included in the client's care plan?

The nurse is caring for a client on the neurologic medical-surgical unit who was admitted for a new onset of cerebrovascular attack. The client has a medical history of hypertension and diabetes. While conducting a neurologic assessment, how should the nurse assess the oculomotor nerve?

While completing a comprehensive assessment of a client who is admitted with chronic obstructive pulmonary disorder, the objective data revealed the client's nails appear convexed and wide with an angle greater than 160 degrees. How would the nurse document this finding?

A nurse should ask the client to assume which position to begin the examination of the breast?

A nurse is preparing to administer amoxicillin 100 mg PO every 8 hr to a toddler who weighs 20 kg. The recommended dosage range is 20 to 25 mg/kg/day. Which action by the nurse is appropriate?

Upon auscultating a client's lungs, the nurse notes there is a low-pitched, continuous respiratory sound that has a snoring quality. How should the nurse interpret and document the findings?

The nurse is admitting a client to the urgent care center. When taking a health history of an older adult client, the nurse would inquire about a history of which eye conditions. Select the four options that apply.

You are examining a client with respiratory distress. Which physical assessment would best determine if the client has acute hypoxemia?