A client is admitted with high fever of 102°F orally and an elevated WBC of 15,000. They state they have had a sinus infection and a sore throat for over 24 hours. A nurse is preparing to palpate the client's lymph nodes. At what anatomic location should the nurse position his or her hands to assess the submental lymph node?
At the base of the client's skull
At the angle of the client's jaw
Behind the tip of the client's chin
On the area behind the client's ears
The Correct Answer is C
Choice A reason: The base of the skull houses occipital nodes, not submental ones, which drain the lower face. Palpating here misses the submental region, irrelevant to sinus or throat infections, misaligning with lymphatic drainage patterns in this case.
Choice B reason: The angle of the jaw targets submandibular nodes, not submental, which sit midline under the chin. This area drains the jaw and mouth but not specifically the submental zone tied to the client’s symptoms directly.
Choice C reason: Behind the chin tip is the submental node location, draining the lower lip, tongue, and anterior mouth. With sinus and throat infection, this spot is key for detecting lymphadenopathy linked to the client’s fever and elevated WBC.
Choice D reason: Behind the ears assesses postauricular nodes, unrelated to submental drainage of the chin and mouth. This misses the infection’s likely lymphatic response, focusing on a region not typically involved in sinus or throat pathology here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Impaired judgment suggests frontal lobe pathology, like dementia, not normal aging. Age-related changes slow processing, not executive function, making this a disease sign, not a typical neurological shift in an 81-year-old fully here.
Choice B reason: Loss of remote memory indicates Alzheimer’s, not normal aging. Aging may slow recall, but long-term memory typically persists, excluding this as an expected age-related change in this neurological assessment entirely and accurately here.
Choice C reason: Intention tremors signal cerebellar disease, like Parkinson’s, not aging. Normal aging may reduce fine motor speed, but not cause action tremors, distinguishing this as pathological, not a standard age-related finding fully here.
Choice D reason: Reduced distal sensation, from nerve conduction slowing, is a common age-related change. Aging thins myelin, impairing peripheral nerves, making this the expected finding in an 81-year-old’s neurological exam accurately and comprehensively here.
Correct Answer is C
Explanation
Choice A reason: Angle closure glaucoma causes peripheral vision loss and pain from pressure, not central loss. This acute condition contrasts with the client’s central vision complaint, excluding it as the suspected diagnosis in this scenario entirely here.
Choice B reason: Presbyopia blurs near vision from lens stiffness, not central loss. This age-related change affects focus, not macular function, making it unrelated to the specific central vision impairment the client reports fully and accurately here.
Choice C reason: Macular degeneration degrades central vision via retinal damage, common in older adults. This matches the client’s loss, as the macula processes sharp central sight, making it the likely suspect for this visual complaint comprehensively here.
Choice D reason: Cataracts cause diffuse blurriness, not isolated central loss. Lens opacity scatters light broadly, differing from macular-specific damage, rendering this less likely than macular degeneration for the client’s central vision issue fully here.
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