During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

Tactile fremitus

Crepitus.

Adventitious sounds.

Friction rub

Answer and Explanation

The Correct Answer is B

A.   This is a vibration felt on the chest wall when a patient speaks, often used to assess lung sounds. It is not associated with the crackling sensation described here.
B.   The coarse, crackling sensation felt on the skin surface when palpating is crepitus, which occurs when air escapes into the subcutaneous tissue, often due to trauma, infection, or the presence of a pneumothorax.
C.   These are abnormal lung sounds, such as crackles, wheezes, or rhonchi, heard with a stethoscope during auscultation, not felt on the chest wall during palpation.
D.   A friction rub is a grating or scraping sound heard with a stethoscope, typically due to inflammation of the pleural surfaces. It is not a sensation felt on the chest wall.

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

Explanation

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.

A. Improper positioning B. Fatigue or weakness C. Respiratory distress D. Increased comfort and relaxation

Correct Answer is C

Explanation

A. Improper positioning does not apply in this case; the position described is often associated with respiratory distress.
B. Fatigue or weakness may be present, but the described position is more indicative of difficulty breathing.
C. Respiratory distress is suggested by the patient leaning forward, which is a common position for patients with shortness of breath as it helps expand the lungs and ease breathing.
D. Increased comfort and relaxation is unlikely; this position is more often associated with discomfort and difficulty breathing.

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During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

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Naxlex Comprehensive Predictor Exams

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.

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

Explanation

Mrs. Helms is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?

Correct Answer is C

Explanation

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