The nurse is examining a female client who states, she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Recent over-the-counter infection cures.

Nontender, firm lymph nodes.

Number of indoor cats at home.

Amount of daily caffeine consumption.

Answer and Explanation

The Correct Answer is B

A. Recent over-the-counter infection cures. This is less immediately relevant unless directly related to lymph node changes.

B. Nontender, firm lymph nodes. This is the correct choice. Nontender, firm lymph nodes can indicate a more serious underlying condition such as malignancy or chronic infection and require further investigation.

C. Number of indoor cats at home. This might be relevant if there is a concern for cat scratch disease, but it is less critical than the nature of the lymph nodes.

D. Amount of daily caffeine consumption. This is not related to the palpation of lymph nodes and is not immediately relevant to the findings.

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Correct Answer is A

Explanation

A. Color characteristics of each stool. This is the best choice as it provides important information about the possible source and nature of the bleeding (e.g., bright red indicates lower GI bleeding, while dark tarry stools indicate upper GI bleeding).
B. Number of blood clots expelled with each stool. While this could be relevant, it is less commonly noted and might be more subjective unless quantified consistently.
C. Unique odor noted with gastrointestinal bleeding. The odor can sometimes indicate the presence of blood, but it is not a primary characteristic to document compared to stool color and consistency.
D. Evidence of internal hemorrhoids. Internal hemorrhoids might be a source of bleeding, but this requires confirmation through a physical examination, typically by a healthcare provider.

A. Document the presence of borborygmi. B. Use the bell of the stethoscope to auscultate again. C. Elevate the head of the client's bed immediately. D. Auscultate the remaining two quadrants.

Correct Answer is A

Explanation

A. Document the presence of borborygmi. This is the best choice as loud, high-pitched gurgling indicates normal borborygmi, which are continuous bowel sounds.

B. Use the bell of the stethoscope to auscultate again. The diaphragm is more suitable for bowel sounds; using the bell is unnecessary.

C. Elevate the head of the client's bed immediately. Elevating the head is not indicated for assessing bowel sounds.

D. Auscultate the remaining two quadrants. While thorough auscultation is important, the findings in two quadrants are sufficient to document normal bowel sounds.

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The nurse is examining a female client who states, she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating a client's rectal bleeding, which findings should the nurse document?

Correct Answer is A

Explanation

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Correct Answer is A

Explanation

Patient Data Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

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While observing a client's face, which assessment finding requires immediate intervention by the nurse?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?