During an admission assessment of a client, the nurse palpates enlarged axillary lymph nodes. Which question should the nurse ask the client related to this finding?

Do you have a history of cardiac disease?

Have you had a recent infection?

Are you having any shortness of breath?

Have you had surgery on your neck?

Answer and Explanation

The Correct Answer is B

Choice A reason: A history of cardiac disease is not directly related to enlarged axillary lymph nodes. Cardiac disease may affect the heart, blood vessels, and circulation, but not the lymphatic system. ¹

Choice B reason: A recent infection is a possible cause of enlarged axillary lymph nodes. Lymph nodes are part of the immune system and they swell when they are fighting an infection. ² The nurse should ask the client about any signs or symptoms of infection, such as fever, sore throat, or skin rash.

Choice C reason: Shortness of breath is not directly related to enlarged axillary lymph nodes. Shortness of breath may indicate a respiratory problem, such as asthma, bronchitis, or pneumonia. ³ However, these conditions do not usually affect the lymph nodes in the armpit area.

Choice D reason: Surgery on the neck is not directly related to enlarged axillary lymph nodes. Surgery on the neck may affect the lymph nodes in the neck or the collarbone area, but not the lymph nodes in the armpit area. The nurse should ask the client about any history of surgery or trauma to the lymph nodes or the surrounding tissues.

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Correct Answer is C

Explanation

Choice A reason: The second intercostal space, right of sternum, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The second intercostal space, right of sternum, is the location where the aortic valve can be best heard, but not the location where the aortic murmur will be most audible. ³

Choice B reason: The third intercostal space, left of sternum, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The third intercostal space, left of sternum, is the location where the pulmonary valve, which separates the right ventricle and the pulmonary artery, can be best heard, but not the location where the aortic murmur will be most audible. ³

Choice C reason: The second intercostal space, left of sternum, is the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The second intercostal space, left of sternum, is the location where the aortic murmur will be most audible, as it is the closest to the aorta, the largest artery in the body. ³

Choice D reason: The fourth intercostal space, left mid-clavicular line, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The fourth intercostal space, left mid-clavicular line, is the location where the tricuspid valve, which separates the right atrium and the right ventricle, can be best heard, but not the location where the aortic murmur will be most audible. ³

A. Cucumbers B. Bran C. Celery D. Spinach

Correct Answer is D

Explanation

Choice A reason: Cucumbers are not a good source of iron for the client with iron-deficiency anemia. Iron-deficiency anemia is a condition where the body does not have enough iron to produce hemoglobin, the protein that carries oxygen in the red blood cells. Cucumbers are mostly water and have very little iron content. The client should eat foods that are rich in iron, such as meat, poultry, fish, eggs, beans, and leafy green vegetables.

Choice B reason: Bran is not a good source of iron for the client with iron-deficiency anemia. Bran is the outer layer of cereal grains that contains fiber and some minerals, but not much iron. Bran can also interfere with the absorption of iron from other foods by binding to it and preventing it from entering the bloodstream. The client should avoid eating bran or other foods that contain phytates, oxalates, or tannins, which can reduce the bioavailability of iron.

Choice C reason: Celery is not a good source of iron for the client with iron-deficiency anemia. Celery is a low-calorie vegetable that has some vitamins and minerals, but very little iron. Celery also has a high water content and can fill up the stomach without providing much nutrition. The client should eat foods that are high in iron, such as meat, poultry, fish, eggs, beans, and leafy green vegetables.

Choice D reason: This is the correct answer. Spinach is a good source of iron for the client with iron-deficiency anemia. Spinach is a leafy green vegetable that has a high iron content and can help increase the hemoglobin level and the oxygen-carrying capacity of the blood. Spinach also has other nutrients, such as vitamin C, folate, and antioxidants, that can benefit the health of the client. The client should eat spinach and other foods that are high in iron, such as meat, poultry, fish, eggs, beans, and leafy green vegetables.

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During an admission assessment of a client, the nurse palpates enlarged axillary lymph nodes. Which question should the nurse ask the client related to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse auscultates a heart murmur on a client with cardiovascular disease. At which anatomic landmark will an aortic murmur be heard the loudest?

Correct Answer is C

Explanation

When developing a plan of care for the client diagnosed with iron-deficiency anemia, the nurse would encourage intake of which foods?

Correct Answer is D

Explanation

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