Question

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

Answer 1

Correct Answers:

Non-painful enlarged interphalangeal joints.

Rationale :

⭐ Heberden’s nodes are bony, non-painful nodules located at the distal interphalangeal joints of the fingers, characteristic of osteoarthritis.

⭐ They develop due to chronic joint degeneration and osteophyte formation.

⭐ Unlike rheumatoid arthritis, osteoarthritis nodules are usually painless and do not cause joint deviation.

⭐ Documenting this finding provides evidence of chronic joint changes.

⭐ Nurses must distinguish between osteoarthritis (non-inflammatory, bony nodes) and inflammatory arthritis.

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Answer 2

Correct Answers:

Normal bowel sounds.

Rationale :

⭐ Normal bowel sounds consist of gurgling or bubbling sounds occurring every 5–15 seconds, lasting a few seconds.

⭐ Hyperactive bowel sounds are more frequent, while hypoactive are less frequent.

⭐ Borborygmi are loud, rumbling sounds associated with hunger or hypermotility.

⭐ The nurse should document this finding as normal bowel sounds in all four quadrants.

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Answer 3

Correct Answers:

Muscle tone
Pupil size
Level of consciousness
Glasgow coma scale
Cranial nerves

Rationale :

⭐ A focused neurological assessment includes LOC, pupil size and reactivity, cranial nerve function, muscle tone/strength, and Glasgow Coma Scale scoring.

⭐ Brudzinski reflexes assess meningitis, not relevant here.

⭐ Romberg’s test is for balance (cerebellar function) but not a priority after a fall with dizziness.

⭐ These key assessments establish a baseline for neurological status.

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Answer 4

Correct Answers:

Begin with questions that are less sensitive in nature.

Rationale :

⭐ When interviewing about mental health, start with general, less sensitive questions to build trust and rapport.

⭐ Gradually progress to more sensitive questions once the client feels comfortable.

⭐ Asking vague questions leads to unclear information, and starting with the hardest questions may cause withdrawal.

⭐ Nurses must avoid sharing personal values, which can bias the discussion.

⭐ This patient-centered approach improves communication and assessment accuracy.

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Answer 5

Correct Answers:

The gallbladder is normal.

Rationale :

⭐ The normal gallbladder is not palpable during physical exam unless it is inflamed or enlarged (e.g., cholecystitis).

⭐ Obesity may make palpation more difficult, but even in thin clients, a normal gallbladder usually cannot be felt.

⭐ Incorrect quadrant palpation would reveal other organs, not gallbladder.

⭐ Nurses document inability to palpate the gallbladder as a normal finding.

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Answer 6

Correct Answers:

Body weight, hirsutism, thyroid enlargement.

Rationale :

⭐ In a young woman with missed periods and negative pregnancy test, assessing for hormonal/endocrine causes is essential.

⭐ Polycystic ovary syndrome (PCOS) is associated with irregular menses, hirsutism, obesity, and possible thyroid disorders.

⭐ Vaginal discharge or tremors are unrelated primary causes for amenorrhea.

⭐ Early identification ensures timely referral for endocrine or gynecologic evaluation.

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Answer 7

Correct Answers:

Dried dark red blood on swollen external hemorrhoids.

Rationale :

⭐ The described finding of a purple, shiny mass protruding from the anal opening with dried blood is consistent with external hemorrhoids.

⭐ Hemorrhoids are dilated rectal veins that can bleed, especially with straining.

⭐ Anal fissures (tears) cause sharp pain and bright red blood, while prolapse appears as mucosal tissue without shiny nodules.

⭐ Documenting hemorrhoids ensures proper diagnosis and treatment planning.

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Answer 8

Correct Answers:

Advise the client to see his healthcare provider for immediate evaluation.

Rationale :

⭐ A mole that is changing color, enlarging, or irregular is suspicious for melanoma and requires immediate referral.

⭐ Monitoring or teaching family to check delays treatment.

⭐ Asking about sun exposure does not address the priority concern.

⭐ Nurses must recognize ABCDE signs of melanoma (Asymmetry, Border, Color, Diameter, Evolving).

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Answer 9

Correct Answers:

Listen to the heart sounds using the bell of a stethoscope.

Rationale :

⭐ The bell of the stethoscope is best for detecting low-pitched extra heart sounds like S3 and S4.

⭐ The diaphragm detects high-pitched sounds like murmurs and clicks.

⭐ Pulse oximetry or Doppler does not help confirm heart sounds.

⭐ Proper technique ensures accurate cardiovascular assessment.

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Answer 10

Correct Answers:

Ask the client about any localized tenderness at the site.

Rationale :

⭐ An enlarged lymph node should be further assessed for tenderness, mobility, and consistency.

⭐ Tender nodes often indicate infection, while hard, immobile nodes may suggest malignancy.

⭐ Enlarged lymph nodes are not normal findings and should not be documented as such.

⭐ Auscultating a lymph node for bruit is not relevant, and covering it provides no diagnostic information.

⭐ Nurses assess characteristics before reporting to the provider.

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QLexNursing

1 :
During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

2 :
While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

3 :
The client is a 76-year-old female who arrived at the emergency department (ED).

Answer Options

5 :
While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

8 :
A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

9 :
The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

10 :
The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

QLexNursing

1 : During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

2 : While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

3 : The client is a 76-year-old female who arrived at the emergency department (ED).

Answer Options

5 : While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

8 : A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

9 : The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

10 : The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

1 :
During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

2 :
While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

3 :
The client is a 76-year-old female who arrived at the emergency department (ED).

5 :
While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

8 :
A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

9 :
The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

10 :
The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?