These are two NCLEX review questions for health assessment. These questions provide two scenarios about performing a head-to-assessment on a patient and requires you to use nursing knowledge in how you will proceed with the assessment, along with identifying lymph nodes in the neck.
This question is one of the many questions we will be practicing in our new series called “Weekly NCLEX Question”.
So, every week be sure to tune into our YouTube Channel for the NCLEX Question of the Week.
Health Assessment NCLEX Style Questions
You’re performing a head-to-toe assessment on a patient admitted with abdominal pain. During inspection of the abdomen, you note the abdominal contour to be round and distended with no masses or lesions present. The patient reports that their last bowel movement was one hour ago, and the stool was loose. In addition, the patient states that the abdominal pain is located below the umbilicus and is sharp in quality. After inspection of the abdomen, you will:
A. Perform light palpation on the abdomen, followed by deep palpation.
B. Percuss the abdomen.
C. Auscultate for bowel sounds by starting in the right lower quadrant.
D. Palpate for bruits and rebound tenderness.
To answer this question, you want to think about the sequence in how you assess each system of the body.
Normally, the nurse will:
BUT this is not the case with the abdomen! Auscultation will be second instead of last. Therefore, the sequence will be like this:
Based on the scenario, we have already INSPECTED the abdomen. Now, it is time to auscultate it.
WHY is this process switched for the abdomen? Because when you palpate and percuss the abdomen you are pushing on the intestines, which contain gastric contents. As you push around on the abdomen, this can alter bowel sounds that may have not presented normally if you didn’t cause them to. Therefore, you want to auscultate before you even touch the abdomen. Auscultating will include listening to bowel sounds and vascular sounds (aorta, renal artery, iliac artery, and femoral artery) for bruits.
Therefore, the answer is C.
You’re performing a head-to-toe assessment on a patient. While palpating the lymph nodes of the neck, the patient reports tenderness at the following location.
When you document the findings of the head-to-toe assessment, you will note that the patient felt tenderness at which lymph node site?
C. Superficial cervical
To answer this question, you must think back to your health assessment knowledge regarding the locations and names of each lymph node site in the neck.
The names of the main lymph nodes in the neck are:
- Jugulodigastric (Tonsillar)
- Superficial Cervical
- Deep Cervical Chain
- Posterior Cervical
Their locations are here:
The answer is D.