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 C

Explanation

A. Distraction and relaxation techniques may help manage general discomfort but are not appropriate when a specific physical finding, such as rebound tenderness, indicates a potential acute abdominal condition.
B. Catheterizing the bladder is not related to the finding of rebound tenderness, which is more likely indicative of an underlying condition such as appendicitis or peritonitis.
C. Rebound tenderness is a significant finding that can indicate peritoneal irritation, such as from appendicitis. The healthcare provider should be notified immediately so that further diagnostic evaluation and appropriate treatment can be initiated.
D. Administering a laxative without further assessment could exacerbate the condition if the underlying cause is an acute abdominal process, such as appendicitis, which requires surgical intervention rather than bowel stimulation.

A. Recent candida infection. B. Diabetes mellitus. C. Coronary heart disease. D. Iron deficiency anemia.

Correct Answer is D

Explanation

A. A recent Candida infection could affect the nails, but it typically causes nail thickening and discoloration rather than brittle, concave nails.
B. Diabetes mellitus can lead to various nail changes, including thickening and yellowing, but it is not commonly associated with brittle, concave nails.
C. Coronary heart disease may cause changes in the nails due to poor circulation, but it is not specifically linked to brittle, concave nails.
D. Iron deficiency anemia is commonly associated with brittle, concave nails, a condition known as koilonychia. This nail abnormality is a classic sign of iron deficiency and warrants further investigation.

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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

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

Correct Answer is D

Explanation

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