You are beginning your shift on a medical unit and are performing assessments appropriate to each patients diagnosis and history. When assessing a patient who has an acute staphylococcal infection, what Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 15e 87 is the most effective technique for assessing the lymph nodes of the patients neck?

Correct Answer: C

Rationale: The correct answer is C: Palpation. When assessing lymph nodes in the neck, palpation is the most effective technique. Palpation allows the nurse to feel for any enlargement, tenderness, or firmness in the lymph nodes, which can indicate infection or inflammation. Inspection (A) involves visual examination and may not provide as much information as palpation. Auscultation (B) involves listening with a stethoscope and is not typically used for assessing lymph nodes. Percussion (D) involves tapping on the body to assess underlying structures and is not commonly used for assessing lymph nodes. Palpation is the preferred method for assessing lymph nodes due to its ability to detect abnormalities through touch.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Unintended weight loss in an elderly patient can be a sign of malnutrition. 2. Ill-fitting dentures and limited intake of high-fiber foods can lead to poor nutrient absorption. 3. Malabsorption of nutrients can result in weight loss despite adequate calorie intake. 4. Therefore, the patient is at risk for malabsorption of nutrients, making choice C the correct answer. Summary: A: Constipation - Not directly related to the patient's unintended weight loss and dietary habits. B: Deficient fluid volume - Unlikely to be the primary issue causing the weight loss in this case. D: Excessive intake of convenience foods - Opposite of the patient's limited intake of high-fiber foods and not related to malabsorption.

Correct Answer: B

Rationale: The correct answer is B: Where exactly is your abdominal pain and when did it start? This question is specific, focused on the patient's chief complaint, and helps in understanding the location and onset of the pain. It allows for a targeted assessment and aids in determining the possible cause of the pain. A: Why do you think your abdomen is painful? - This question is vague and may not provide precise information about the location and onset of the pain. C: What brings you to the hospital today? - This question is general and may not address the specific concern of abdominal pain. D: What is wrong with you today? - This question is broad and may not help in obtaining detailed information about the abdominal pain.

Correct Answer: C

Rationale: The correct answer is C: "What limitations are you dealing with related to your health and being in a wheelchair?" This question is the most appropriate as it directly addresses the patient's current health status and the impact of being wheelchair-bound on his daily life. It shows a focus on assessing the patient's functional status and potential challenges he may be facing due to his condition. Choice A is incorrect because while knowing about the patient's medications and how he obtains them is important, it does not directly address the impact of his current health status and wheelchair use. Choice B is incorrect as it focuses on the patient's living situation rather than his health status and wheelchair limitations. Choice D is incorrect as it is a vague and open-ended question that does not specifically address the patient's health status and the impact of being wheelchair-bound. In summary, choice C is the correct answer as it directly addresses the patient's health and functional limitations, which are crucial for providing appropriate care and support.

Correct Answer: A

Rationale: The correct answer is A because listening to body sounds using a stethoscope is called auscultation, not palpation. Using a diaphragm is essential for hearing heart murmurs clearly. It requires a trained ear to distinguish the sounds accurately. Choice B is incorrect because palpation involves feeling with hands, not listening with a stethoscope. Choice C is incorrect because not all heart murmurs are pathologic and require surgery. It is important to provide accurate information to the patient. Choice D is incorrect because it does not mention the correct term "auscultation" and lacks the essential information about using a stethoscope with a diaphragm.