A nurse is performing a lymphatic system assessment on a client reporting fatigue and malaise for one week. In which order should the nurse perform the head to toe assessments? Indicate the correct order from first to last. All options must be used.

Palpate the popliteal nodes

Palpate the preauricular nodes

Palpate the axillary nodes

Palpate the submandibular nodes

Palpate the supraclavicular nodes

Answer and Explanation

The Correct Answer is {"A":{"answers":"E"},"B":{"answers":"A"},"C":{"answers":"D"},"D":{"answers":"B"},"E":{"answers":"C"}}

Palpate the preauricular nodes (1st):

The preauricular lymph nodes are located in front of the ears, near the temple. The nurse starts at the head and neck to assess the regional nodes. Palpation of the preauricular nodes is often performed first because they are closest to the head and may be involved in infections affecting the eyes, ears, or sinuses.

Palpate the submandibular nodes (2nd):

The submandibular nodes are located beneath the jaw and are often involved in respiratory or oral infections. They are assessed after the preauricular nodes, as they are still part of the head and neck region, just below the chin.

Palpate the supraclavicular nodes (5th):

These nodes are located above the clavicle and are often associated with more serious conditions, such as cancer. Assessing them early in the examination can help identify any potential red flags.

Palpate the axillary nodes (3rd):

The axillary lymph nodes are located in the armpits and are important for breast tissue, upper limb, and chest infections. These are assessed after the head and neck nodes because they are part of the upper body region and located further down, near the chest.

Palpate the popliteal nodes (4th):

The popliteal nodes are located behind the knees. These nodes are assessed next, as part of the lower extremity examination. Palpating these nodes after the axillary nodes ensures a thorough systematic approach from upper to lower body.

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Correct Answer is C

Explanation

A. Peripheral vascular disease involves issues with blood flow to the extremities but does not typically present with jugular vein distension or a gallop heart sound.
B. Fluid and electrolyte disturbances may affect heart rhythm and fluid balance but are less likely to present with these specific findings.
C. Heart failure is the most likely cause, as jugular vein distension and a third heart sound (S3 gallop) are common signs of heart failure, particularly when the heart cannot effectively pump blood.
D. Atrial-septal defect may cause heart murmurs or irregular rhythms but is not typically associated with jugular vein distension or an S3 gallop.

A. Trapezius B. Diaphragm C. Rectus abdominus D. Sternocleidomastoid

Correct Answer is B

Explanation

A. Trapezius: The trapezius is a muscle of the upper back and neck and does not play a primary role in normal respiration.
B. Diaphragm: The diaphragm is the most important muscle for respiration. It contracts and moves downward during inhalation, increasing the thoracic cavity's volume and drawing air into the lungs.
C. Rectus abdominus: The rectus abdominus is a core muscle that helps in forced expiration but is not essential in normal breathing.
D. Sternocleidomastoid: This muscle assists with forced inspiration, but it is not the primary muscle for regular breathing.

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A nurse is performing a lymphatic system assessment on a client reporting fatigue and malaise for one week. In which order should the nurse perform the head to toe assessments? Indicate the correct order from first to last. All options must be used.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a cardiac assessment of a client you observed jugular vein distension, and auscultated $3 gallop heart sound. These findings most likely suggest which of the following conditions?

Correct Answer is C

Explanation

Which of the following is the most important muscle in the normal respiratory process of an adult?

Correct Answer is B

Explanation

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During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

The RN is explaining to an elderly client why the skin folds and sags as part of the normal aging process. What is the correct mechanism for this?

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?

A nurse is performing a lymphatic system assessment on a client reporting fatigue and malaise for one week. In which order should the nurse perform the head to toe assessments? Indicate the correct order from first to last. All options must be used.

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