The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

Nodes feel ropey and rubbery.

Axillary nodes feel soft and fatty.

Inguinal nodes are enlarged and warm to the touch.

Nodes are non-palpable.

Answer and Explanation

The Correct Answer is D

A. Lymph nodes that feel ropey and rubbery might indicate chronic inflammation or fibrosis. This texture is not typically considered normal. In elderly clients, lymph nodes may become less palpable due to age- related changes, but they should not feel ropey or rubbery. If lymph nodes feel this way, it may warrant further investigation to rule out pathological conditions.
B. In elderly clients, axillary lymph nodes may feel softer and less defined due to fatty tissue changes associated with aging. However, "soft and fatty" should be interpreted cautiously. While some degree of change is normal, nodes should not be excessively soft, nor should they have an abnormal appearance. The key is that they should not be hard, fixed, or tender, which would be indicative of pathology.
C. Enlarged and warm inguinal lymph nodes suggest infection or inflammation rather than a normal finding. In the elderly, while lymph nodes can sometimes be palpable, they should not be enlarged or warm, as this could indicate an underlying condition or infection that requires further evaluation.
D. It is normal for lymph nodes to be non-palpable in many individuals, including older adults. Age- related changes can cause lymph nodes to be less prominent or difficult to palpate. If lymph nodes are non-palpable, it usually means they are not enlarged or abnormal, which is a normal finding, especially if the client is not experiencing any symptoms of infection or other related issues.

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Correct Answer is B

Explanation

A. Soft tissue, such as the liver or spleen, typically produces a dull sound on percussion, not a high- pitched musical sound. Soft tissue is more associated with a dullness because it is denser compared to the surrounding air or fluids.
B. Gas in the gastrointestinal tract often produces a musical or high-pitched sound on percussion, known as tympany. This sound occurs because gas is less dense than other abdominal contents and resonates with a high pitch. Tympany is the most common sound heard when percussing over the stomach and intestines.
C. An intestinal mass, depending on its size and location, may produce a dull or a combination of dull and tympanic sounds. However, it is not typically associated with a high-pitched musical sound. Percussion over an intestinal mass would likely be dull rather than musical.
D. A full bladder typically produces a dull sound on percussion, not a musical high-pitched sound. A dull sound indicates the presence of a solid or fluid-filled structure, such as a full bladder.

A. Ask the client to perform light exercise and observe the respiratory effort. B. Document "dyspnea on exertion" in the client's medical record. C. Ask the client to describe the episodes of dyspnea in more detail. D. Explain to the client the possible causes of dyspnea or "shortness of breath."

Correct Answer is C

Explanation

A. Performing light exercise may help in assessing how the client’s respiratory system responds to physical exertion and could reveal if the shortness of breath is related to activity. However, this action might not be appropriate if the client is currently asymptomatic or if the nurse needs more detailed information about the episodes of dyspnea.
B. Documenting "dyspnea on exertion" might be appropriate if the nurse has already confirmed that the shortness of breath occurs specifically with physical activity. However, based on the information provided, the nurse has not yet gathered sufficient details to confirm whether the dyspnea is related to exertion or another cause.
C. This option is the best initial action because it allows the nurse to gather detailed information about the nature, frequency, duration, and triggers of the client's shortness of breath. Understanding the context and specifics of the episodes will help in determining whether the dyspnea is related to underlying health issues, activity, or other factors.
D. While explaining the possible causes of dyspnea can be informative for the client, it may not address the immediate need for a detailed assessment of the client's symptoms. Providing education is valuable, but understanding the client's specific experience with dyspnea should take precedence to tailor the explanation and subsequent care effectively.

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The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While percussing the abdomen of an adult male client, the nurse encounters a musical high-pitched sound. Which does this finding indicate?

Correct Answer is B

Explanation

While obtaining a health history, a client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirations are regular and deep, and his respiratory rate is 14 breaths/minute. What is the best nursing action?

Correct Answer is C

Explanation

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