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. Performing a mental status exam is important but may not be the immediate priority if the issue could be related to a more straightforward problem such as hearing loss.
B. Orienting the client to her surroundings is helpful but may not address the immediate concern of her ignoring questions, which could be due to hearing issues.
C. Standing directly in front of the client and asking about hearing loss addresses a possible issue with communication immediately. It is crucial to rule out hearing impairment before assuming other causes for the client's behavior.
D. Using a tuning fork to complete Rinne and Weber tests is a valid assessment for hearing loss but is a more specific test that may be implemented after the nurse initially assesses whether hearing loss is a potential issue.

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?

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Correct Answer is C

Explanation

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Correct Answer is D

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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?