An adult client comes to the clinic and reports concern over a lump that, "Just popped up on my neck about a week ago." While performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. Which of these findings suggest?

Lymphangitis.

Malignancy.

Viral Infection.

Bacterial Infection.

Answer and Explanation

The Correct Answer is B

A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.

B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.

C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.

D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.

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Correct Answer is B

Explanation

A. Respiratory acidosis. Respiratory acidosis occurs when there is hypoventilation, leading to an accumulation of carbon dioxide and increased acidity in the blood. Hyperventilation, as described in the scenario, would not lead to respiratory acidosis.
B. Respiratory alkalosis. Hyperventilation leads to respiratory alkalosis by blowing off excessive carbon dioxide, resulting in decreased levels of carbonic acid and increased blood pH.
C. Metabolic acidosis. Metabolic acidosis results from an accumulation of acids or loss of bicarbonate ions. The scenario does not indicate factors leading to metabolic acidosis.
D. Metabolic alkalosis. Metabolic alkalosis occurs due to excessive loss of acids or increased bicarbonate levels, neither of which is suggested in the scenario.

A. Do not take any over-the-counter medications. B. Eat a high carbohydrate, low fat, low protein diet. C. Call the crisis hot line if feeling lonely. D. Avoid exposure to large crowds.

Correct Answer is A

Explanation

A. Do not take any over-the-counter medications. This is crucial because many over-the-counter medications, including those containing acetaminophen, can further damage the liver. Avoiding these medications is essential to prevent further hepatic injury.
B. Eat a high carbohydrate, low fat, low protein diet. While diet can influence liver health, this specific dietary advice is less critical than preventing further liver damage from medications.
C. Call the crisis hot line if feeling lonely. This is important for mental health support, but the immediate physical health concern related to liver damage takes precedence.
D. Avoid exposure to large crowds. This may be relevant if the client is immunocompromised due to liver damage, but it is not as directly related to preventing further liver injury as avoiding certain medications.

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Naxlex Comprehensive Predictor Exams

An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

Correct Answer is B

Explanation

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

Correct Answer is A

Explanation

A school-aged client was recently diagnosed with type 1 diabetes mellitus. Which symptom did the client's parents most likely report?

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?

Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy?

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

The nurse is collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?