The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

Size

Consistency

Shape

Color

Answer and Explanation

The Correct Answer is D

A) Size:

When assessing lymph nodes, noting the size is crucial as enlarged lymph nodes can indicate infection, inflammation, or malignancy. Size helps in determining the extent and severity of the underlying condition.

B) Consistency:

The consistency of lymph nodes (whether they are hard, rubbery, or soft) provides important diagnostic information. For instance, hard lymph nodes may suggest malignancy, while soft nodes might indicate an infection.

C) Shape:

Recording the shape of lymph nodes is essential in the assessment process. Regular, oval, or round shapes can be normal, while irregularly shaped nodes might be concerning and warrant further investigation.

D) Color:

Color is not typically assessed or noted when examining lymph nodes. Lymph nodes are internal structures, and their color cannot be directly observed without invasive procedures. The focus is usually on palpable characteristics like size, consistency, and shape.

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Correct Answer is A

Explanation

A) Obesity II:

A Body Mass Index (BMI) of 37 falls within the range of 35 to 39.9, which is classified as Obesity Class II according to the World Health Organization (WHO) BMI categories. This classification indicates a higher risk of obesity-related health conditions and complications.

B) Overweight:

The overweight category corresponds to a BMI range of 25 to 29.9. A BMI of 37 is significantly higher than this range, indicating a more severe level of excess weight and associated health risks.

C) Normal weight:

Normal weight is defined by a BMI range of 18.5 to 24.9. A BMI of 37 is well above this range, indicating that the patient has excess body weight far beyond what is considered normal.

D) Obesity:

While the term "obesity" generally refers to a BMI of 30 or higher, specific classes of obesity (Class I, II, and III) are defined for more precise categorization. A BMI of 37 specifically places the patient in the Obesity II category.

A. to prevent further dehydration B. to assist the client to feel more comfortable C. to observe the movement of the thyroid gland D. to promote the nurse-client relationship

Correct Answer is C

Explanation

A. To prevent further dehydration:

While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.

B. To assist the client to feel more comfortable:

Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.

C. To observe the movement of the thyroid gland:

Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.

D. To promote the nurse-client relationship:

Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.

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The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse measures a patient height and weight and calculate his BMI. Patient BMI is 37. Classify according to this BMI results?

Correct Answer is A

Explanation

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

Correct Answer is C

Explanation

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The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding?

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

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