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. Pulse volume is not the same as the presence of a bruit, which is an abnormal sound heard over an artery.
B. A bruit is an abnormal, blowing, or swishing sound heard over an artery, indicating turbulent blood flow, often due to atherosclerosis or narrowing of the artery. Documenting the presence of a bruit on the left and its absence on the right is the correct approach.
C. A strong pulse does not necessarily correlate with the presence of a bruit, and the absence of sound on the right does not confirm occlusion.
D. Occlusion of the artery cannot be confirmed solely based on the absence of a bruit; further diagnostic testing would be required.

A. Impaired memory B. Normal mental status for age C. Impaired concentration D. Impaired thinking

Correct Answer is D

Explanation

A. Impaired memory refers to difficulty in recalling information or events. The client's response does not indicate an issue with memory recall but rather reflects a misinterpretation of the proverb, suggesting that memory impairment is not the correct conclusion.
B. Normal mental status for age would imply that the client's cognitive responses are appropriate for their developmental stage. However, the client's response to the proverb is not consistent with a normal interpretation, indicating that this option is incorrect.
C. Impaired concentration refers to an inability to maintain focus on a task or thought. While concentration issues might lead to incomplete or disjointed responses, the client's answer does not suggest a lack of focus but rather a misinterpretation, which is more indicative of impaired thinking.
D. Impaired thinking is characterized by difficulty in reasoning, understanding, or interpreting information correctly. The client's response to the proverb "Glass Houses" reflects a concrete interpretation rather than the abstract reasoning typically required to understand proverbs, indicating impaired thinking.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Correct Answer is B

Explanation

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

Correct Answer is D

Explanation

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