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. This documentation focuses too much on the client's concern about lung cancer rather than providing specific information about the cough, which is the primary symptom described.
B. This option provides a clear and objective description of the symptom reported by the client, including its duration, which is essential for clinical documentation.
C. While describing the cough as "hacking" and "nonproductive" provides additional details, it may not be necessary unless specifically noted by the client. "Body wracking" is a more vivid and accurate description based on the client's own words.
D. This documentation emphasizes the client's fears about lung cancer rather than detailing the specific symptom (the cough) that is relevant to the current issue.

A. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. B. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. C. Looking at the client from the side, observe the size and shape of the chest wall. D. Place the palm of the hand on the chest wall to feel vibrations while the client speaks.

Correct Answer is D

Explanation

A. Using the fingertips to compress tissue over the lungs for a crackling sensation is not an appropriate method for assessing tactile fremitus. This approach is more related to detecting crepitus or subcutaneous emphysema.
B. Using a stethoscope to listen to and compare breath sounds is useful for assessing lung function and detecting abnormalities like wheezes or crackles but does not assess tactile fremitus.
C. Observing the size and shape of the chest wall provides information about overall lung expansion and structural abnormalities but does not assess tactile fremitus, which involves feeling vibrations.
D. Placing the palm of the hand on the chest wall to feel vibrations while the client speaks is the correct method to assess tactile fremitus. Increased fremitus may indicate pneumonia or other lung abnormalities, as the vibrations are transmitted more effectively through consolidated lung tissue.

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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 B

Explanation

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is D

Explanation

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