Which is a normal characteristic of lymph nodes in a healthy adult patient?

Large and fixed to the tissue

Large and non-mobile

Granular texture

Not palpable

Answer and Explanation

The Correct Answer is D

Choice A reason: Large, fixed lymph nodes suggest pathology, such as malignancy or chronic infection, as they indicate adherence to surrounding tissues. In healthy adults, lymph nodes are typically small and not fixed, making this an abnormal and incorrect characteristic.

Choice B reason: Large, non-mobile lymph nodes may indicate infection or malignancy, as healthy nodes are usually small and mobile. Non-mobility suggests tissue infiltration, which is pathological, making this an incorrect description of normal lymph node characteristics.

Choice C reason: Granular texture is not a standard term for describing lymph nodes. Healthy nodes, when palpable, feel smooth and soft. Granular suggests abnormality, possibly infection or malignancy, making this an inaccurate characteristic for healthy lymph nodes.

Choice D reason: In healthy adults, lymph nodes are typically not palpable, as they are small, soft, and non-tender, blending into surrounding tissues. Palpable nodes often indicate inflammation or pathology, making this the correct description of a normal finding.

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Correct Answer is A

Explanation

Choice A reason: Clubbing, characterized by bulbous nail bed enlargement, is associated with chronic hypoxemia from conditions like asthma or COPD. It results from long-term low oxygen levels, making it the expected finding in this patient with chronic respiratory issues.

Choice B reason: Onychomycosis is a fungal nail infection unrelated to hypoxemia or asthma. Clubbing is directly linked to chronic oxygen deficiency, so this is not the expected nail condition in this patient’s context.

Choice C reason: Spooning (koilonychia) is associated with iron deficiency anemia, not hypoxemia or asthma. Clubbing is the nail abnormality seen in chronic respiratory conditions, so this is incorrect for the patient’s condition.

Choice D reason: Paronychia is an infection around the nail, typically from trauma or bacteria, not hypoxemia. Clubbing is the hallmark nail change in chronic asthma with low oxygen, so this is not the expected finding.

A. Use the Brief Pain Inventory to assess the patient’s pain B. Observe the patient’s body language for pacing and agitation C. Note whether the patient is calling out, groaning, or crying D. Assess the patient’s breathing independent of vocalization E. Have the patient rate pain on a 1-to-10 scale

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: The Brief Pain Inventory relies on verbal or cognitive input, which is unreliable in advanced dementia due to impaired communication and cognition. Patients may not articulate pain, making this tool ineffective for assessing pain in this population.

Choice B reason: Observing body language, like pacing or agitation, is a valid pain indicator in advanced dementia. These nonverbal behaviors reflect discomfort processed by intact pain pathways, despite cognitive decline, making this a reliable assessment method.

Choice C reason: Noting vocalizations like groaning or crying is effective, as these are instinctive responses to pain, even in advanced dementia. These behaviors bypass cognitive deficits, reflecting pain perception in the brain’s nociceptive pathways, making this a correct choice.

Choice D reason: Assessing breathing changes, like rapid or irregular patterns, is a reliable nonverbal pain indicator in dementia. Pain can stimulate the autonomic nervous system, altering respiration independently of vocalization, making this a valid assessment technique.

Choice E reason: A 1-to-10 pain scale requires cognitive ability to quantify and communicate pain, which is impaired in advanced dementia. This method is unreliable, as patients cannot reliably report, making it an incorrect choice for this population.

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Which is a normal characteristic of lymph nodes in a healthy adult patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse examines a patient who has asthma and chronic hypoxemia. The nurse would expect to find which condition of the nails?

Correct Answer is A

Explanation

Which of the following could the nurse use to assess indicators of pain experienced by a patient with advanced dementia? (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

The nurse uses the whispered voice test to assess a patient’s hearing. The nurse is assessing which cranial nerve?

A nurse examines a patient’s tympanic membranes with an otoscope. The nurse understands the normal tympanic membrane exhibits which normal characteristic?

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. How should the nurse document this finding?

A nurse is teaching a patient to perform self-breast examination and tells the patient to pay particular attention to examining the upper outer quadrant of the breast. When asked why, “why,” how should the nurse respond to the patient?

The nurse finds that a patient’s skin tents when assessing skin turgor. How would the nurse interpret this finding?

A nurse is teaching a group of teen women. Which should the nurse discuss as the risk factor most associated with cervical cancer?

In using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glow in the patient’s pupils. Based on this finding, what should the nurse do?

The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?