The nurse is examining a female client who states she has no complaints and 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.

Amount of daily caffeine consumption.

Number of indoor cats at home.

Nontender, firm lymph nodes.

Answer and Explanation

The Correct Answer is D

A. Information about over-the-counter treatments might be relevant but is less critical than the physical findings.
B. Daily caffeine consumption is unlikely to be directly related to the presence of enlarged lymph nodes.
C. Having indoor cats might be relevant if there was suspicion of an infection like toxoplasmosis, but this is not the most immediate concern.
D. Nontender, firm lymph nodes, especially when persistent and not related to a known infection, can be concerning and may indicate malignancy or other serious conditions. This finding should be promptly reported to the healthcare provider for further investigation.

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Correct Answer is B

Explanation

A. The clavicle is a bony structure, and placing the stethoscope over it is not ideal for auscultating breath sounds. Breath sounds are best heard over areas where lung tissue is present, so starting at the clavicle would not provide the most accurate assessment.
B. The lung apex, located just above the clavicle, is the correct starting point for auscultating anterior breath sounds. This location allows the nurse to systematically assess the lung fields from the top down, ensuring that all areas are evaluated.
C. The sternum is located centrally and anteriorly on the chest, but it is not the ideal location to begin auscultation of breath sounds. Breath sounds should be auscultated over lung tissue, not over bone, which can obscure or alter the sounds.
D. The aortic site is used for auscultating heart sounds rather than breath sounds. Starting at this location would be inappropriate for a systematic assessment of the lungs and could lead to missing important breath sounds.

A. Paresthesia. B. Normal sensory finding. C. Marginal decline in sensory function. D. Rebound reaction to the needle points.

Correct Answer is B

Explanation

A. Paresthesia refers to abnormal sensations, such as tingling or numbness, not related to the ability to distinguish between two points.
B. Normal two-point discrimination is approximately 2-5 mm on the fingertips and 8-12 mm on the palms, so sensing two points at 3 mm on the fingertips and 10 mm on the palms is within the normal range for a middle-aged adult. This indicates normal sensory function.
C. Marginal decline in sensory function would be suggested by a significantly increased distance required to perceive two points, but the distances noted here are normal.
D. A rebound reaction refers to a reflex or involuntary response, not to the sensation of two-point discrimination.

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The nurse is examining a female client who states she has no complaints and 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?

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Naxlex Comprehensive Predictor Exams

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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The nurse is examining a female client who states she has no complaints and 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?