When the nurse collects objective data, which finding requires immediate follow-up?

Moist nasal mucosa

Cerumen in the ear

Enlarged lymph node in the neck

Acne lesions on the face and upper chest

Answer and Explanation

The Correct Answer is C

A. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.

B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.

C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.

D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.

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Correct Answer is C

Explanation

A. Diverticulosis: This condition involves the formation of pouches in the colon and is not associated with Murphy's sign.

B. Nephrolithiasis: This refers to kidney stones and is not associated with Murphy's sign.

C. Acute Cholecystitis: Murphy's sign is a clinical test for acute cholecystitis, which is inflammation of the gallbladder. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.

D. Appendicitis: Appendicitis is an inflammation of the appendix and is not related to Murphy's sign.

A. Neuropathic ulcers B. Venous insufficiency ulcers C. Deep vein thrombosis D. Arterial insufficiency ulcers

Correct Answer is D

Explanation

A. Neuropathic ulcers: These ulcers are usually associated with diabetic neuropathy and not primarily with changes in skin color upon elevation or dependency.

B. Venous insufficiency ulcers: These are more commonly associated with symptoms such as swelling, brown pigmentation, and ulcers typically around the ankles.

C. Deep vein thrombosis: DVT is characterized by swelling, redness, and warmth, not typically by changes in skin color with position changes.

D. Arterial insufficiency ulcers: The color changes (pale when elevated and dark red when dependent) are indicative of arterial insufficiency, which can lead to arterial ulcers due to poor blood flow.

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When the nurse collects objective data, which finding requires immediate follow-up?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A positive Murphy's sign is indicative of?

Correct Answer is C

Explanation

During the physical assessment of the peripheral vascular system, a client's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this client is at risk for developing:

Correct Answer is D

Explanation

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