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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Decreasing the incidence of tachycardia is not the main therapeutic effect of atenolol for coronary artery disease. Atenolol is a beta-blocker that lowers the heart rate, but this is not the primary goal of therapy for coronary artery disease. Coronary artery disease is caused by atherosclerosis, which is the buildup of plaque in the arteries that supply the heart. This reduces the blood flow and oxygen to the heart muscle and causes angina, or chest pain.
Choice B reason: Dilating the coronary arteries is not the therapeutic effect of atenolol for coronary artery disease. Atenolol does not directly affect the diameter of the coronary arteries. It works by blocking the beta receptors in the heart and reducing the response to adrenaline and other stress hormones. This lowers the blood pressure and the oxygen demand of the heart.
Choice C reason: This is the correct answer. Decreasing cardiac workload is the therapeutic effect of atenolol for coronary artery disease. Atenolol reduces the contractility and the excitability of the heart muscle, which lowers the force and the frequency of the heartbeats. This decreases the amount of work that the heart has to do and the amount of oxygen that it needs. This helps prevent or relieve anginal attacks and improve the quality of life of the client.
Choice D reason: Increasing the strength of myocardial contraction is not the therapeutic effect of atenolol for coronary artery disease. Atenolol does not increase the strength of myocardial contraction, but rather decreases it. Increasing the strength of myocardial contraction would increase the oxygen demand of the heart and worsen the angina. Atenolol aims to reduce the oxygen demand of the heart and improve the blood supply to the heart.
Correct Answer is D
Explanation
Choice A reason: Respiratory alkalosis is not the correct answer. Respiratory alkalosis is a condition where the blood pH is high (above 7.45) due to low carbon dioxide levels (below 35 mmHg) caused by hyperventilation. The client's blood pH is low (7.2) and the carbon dioxide level is normal (40 mmHg), which does not indicate respiratory alkalosis.
Choice B reason: Metabolic alkalosis is not the correct answer. Metabolic alkalosis is a condition where the blood pH is high (above 7.45) due to high bicarbonate levels (above 26 mEq/L) caused by excessive loss of acids or intake of alkali. The client's blood pH is low (7.2) and the bicarbonate level is low (19 mEq/L), which does not indicate metabolic alkalosis.
Choice C reason: Respiratory acidosis is not the correct answer. Respiratory acidosis is a condition where the blood pH is low (below 7.35) due to high carbon dioxide levels (above 45 mmHg) caused by hypoventilation. The client's blood pH is low (7.2) but the carbon dioxide level is normal (40 mmHg), which does not indicate respiratory acidosis.
Choice D reason: This is the correct answer. Metabolic acidosis is a condition where the blood pH is low (below 7.35) due to low bicarbonate levels (below 22 mEq/L) caused by excessive production or intake of acids or loss of alkali. The client's blood pH is low (7.2) and the bicarbonate level is low (19 mEq/L), which indicates metabolic acidosis.
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