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 B

Explanation

A. Abdominal retraction is typically a sign of acute respiratory distress, not chronic respiratory insufficiency.
B. Clubbing nails occurs as a chronic response to inadequate tissue oxygenation and is often associated with conditions like chronic obstructive pulmonary disease (COPD).
C. Restlessness may occur during acute respiratory distress but is not a typical finding in chronic respiratory insufficiency.
D. Dependent edema 4+ is more related to cardiac conditions such as heart failure rather than respiratory insufficiency, which generally results in more subtle signs like clubbing or cyanosis.

A. Cyst B. Nodule C. Zosteriform D. Ulcer

Correct Answer is C

Explanation

A. Cyst refers to a fluid-filled sac, which does not present as a linear arrangement.
B. Nodule refers to a solid, raised lesion, not linear or along a nerve route.
C. Zosteriform refers to a rash or lesion arranged along a unilateral nerve distribution, often seen with shingles (herpes zoster).
D. Ulcer refers to a loss of skin or mucous membrane, not a linear pattern along a nerve route.

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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

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?

Correct Answer is B

Explanation

A nurse is examining a patient and finds a lesion that is a linear arrangement along a unilateral nerve route. The nurse would document this finding as

Correct Answer is C

Explanation

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