In assessing the lymph nodes of the client's breast, which lymph node will the nurse palpate?

Inguinal nodes.

Subclavicular nodes.

Median lymphatic vessel

Ulnar lymphatic vessel

Answer and Explanation

The Correct Answer is B

A.   The inguinal nodes are located in the groin area. They are not typically assessed when evaluating breast lymph nodes. Instead, these nodes are relevant for assessing the lymphatic drainage of the lower extremities and pelvic region, not the breast.
B.   The subclavicular nodes are located just below the clavicle (collarbone). These nodes are part of the lymphatic drainage system for the breast and are important to assess during a breast examination, especially in the context of breast cancer or other breast conditions. Palpating the subclavicular lymph nodes helps evaluate whether cancer has spread beyond the breast tissue.
C.   The median lymphatic vessel is not a recognized term in standard lymphatic anatomy. Lymphatic vessels are not typically palpated; rather, lymph nodes are assessed. The median term might refer to the midline of the body but does not pertain to a specific lymph node group relevant to breast assessment.
D.   The ulnar lymphatic vessels are related to the lymphatic drainage of the arm, specifically along the ulnar aspect (inner side) of the forearm. These are not relevant to the breast lymph nodes. Assessment of the breast involves checking nodes in the axillary, supraclavicular, and subclavicular regions, not the ulnar lymphatic vessels.

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Correct Answer is ["A","C","D"]

Explanation

A. An elevated temperature is often associated with infections and inflammation, including bronchitis. While a temperature of 99°F is slightly above normal and may indicate a mild fever, it is not a primary hallmark of bronchitis but rather a common response to infection or inflammation.
B. Fatigue is a general symptom that can accompany many conditions, including bronchitis. It is related to the overall feeling of being unwell and is not specific to bronchitis. While fatigue can be present, it is not a definitive sign of bronchitis on its own.
C. This includes findings such as bronchial breath sounds and rhonchi (a type of coarse, rattling sound) noted in the right lower lobe, which are indicative of bronchitis. The presence of rhonchi and bronchial breath sounds suggest inflammation and mucus in the airways, characteristic of bronchitis.
D. The use of accessory muscles for breathing is a sign of respiratory distress, which can occur in bronchitis when the airways are inflamed and obstructed. This finding is consistent with bronchitis as it reflects the increased effort required to breathe due to airway inflammation and mucus production.
E. The blood pressure reading of 110/54 mm Hg is within normal limits and does not provide specific information about bronchitis. Blood pressure is not typically a primary indicator for diagnosing bronchitis.
F. Bowel sounds are related to gastrointestinal function and do not provide information specific to bronchitis. Active bowel sounds are normal and do not help in diagnosing bronchitis.

A. 25 year-old with left arm sling B. 72 year-old with incontinence and dementia C. 82 year-old with an ankle fracture D. 45 year-old post total hysterectomy

Correct Answer is B

Explanation

A. Although this client has an arm sling, which could potentially limit movement and cause some localized pressure, they are generally at a lower risk for widespread skin breakdown compared to older adults. Their younger age and lack of other risk factors make them less susceptible overall.
B. Older adults have thinner skin and decreased elasticity, making them more susceptible to pressure ulcers and skin breakdown. Frequent exposure to moisture from urine or feces can lead to skin irritation and breakdown, especially in areas where skin is already compromised.
C. While an elderly individual with an ankle fracture is at risk for skin breakdown, especially if immobilized and in a cast, this risk is somewhat less immediate compared to someone with incontinence.
D. This client is recovering from surgery, which could include temporary changes in mobility or activity levels. However, they are younger and do not have the additional complicating factors like incontinence or dementia. While there is some risk of skin issues post-surgery, it is not as high as the risk posed by incontinence and cognitive impairment in an elderly client.

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In assessing the lymph nodes of the client's breast, which lymph node will the nurse palpate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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