A nurse is preforming a focus physical assessment of the head and neck of a 20 year old male client. In assessing the lymph nodes what part of the head and neck should the nurse perform gentle circular motion to assess the occipital lymph nodes?
At the base of the skull
In front of the ears
Under the mandible
Above the clavicles
The Correct Answer is A
A) At the base of the skull: The occipital lymph nodes are located at the base of the skull, just above the nape of the neck. The nurse should use a gentle circular motion to palpate the area where these lymph nodes are found. This is the correct location to assess for tenderness, swelling, or abnormalities in the occipital lymph nodes.
B) In front of the ears: The lymph nodes located in front of the ears are known as the preauricular lymph nodes. These are not the occipital lymph nodes. The preauricular nodes are assessed by palpating just in front of the ear, not at the base of the skull.
C) Under the mandible: The submandibular lymph nodes are located under the mandible (lower jaw). These nodes are not the occipital lymph nodes. The nurse would need to palpate under the jawline to assess the submandibular area.
D) Above the clavicles: The supraclavicular lymph nodes are located above the clavicles (collarbones), and they are not the occipital lymph nodes. This area is assessed separately to check for lymph node enlargement or abnormal findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Pearly gray tympanic membrane: A healthy, normal tympanic membrane (eardrum) typically appears pearly gray and translucent. In the case of acute otitis media (AOM), the tympanic membrane usually appears erythematous (red) due to inflammation and may be bulging or swollen. A pearly gray tympanic membrane would be inconsistent with the diagnosis of acute otitis media, as it suggests a lack of infection or inflammation.
B) Erythema tympanic membrane: Erythema, or redness, of the tympanic membrane, is a common finding in acute otitis media. The inflammation from the infection causes the membrane to appear red or inflamed. This finding is consistent with the diagnosis of AOM and indicates irritation or infection in the middle ear.
C) Edema of the tympanic membrane: Edema (swelling) of the tympanic membrane is a common finding in acute otitis media. The middle ear becomes inflamed and fluid-filled, leading to swelling of the tympanic membrane. This is consistent with the diagnosis of AOM.
D) Bulging of the tympanic membrane: Bulging of the tympanic membrane is another classic sign of acute otitis media. The buildup of fluid and pus behind the eardrum causes it to bulge outward. This finding is consistent with AOM and indicates a more severe or advanced stage of the infection.
Correct Answer is B
Explanation
A) 3+: A 3+ tonsil grading indicates that the tonsils are enlarged and occupy more than 75% of the lateral dimension of the oropharynx. The description provided in the question indicates that the tonsils occupy more than 50% but less than 75% of the space, so a 3+ grade is too large to match this description.
B) 2+: A 2+ tonsil grading indicates that the tonsils are enlarged and occupy between 50% and 75% of the lateral dimension of the oropharynx. This matches the description in the question, where the tonsils are smooth, pink, and occupy more than 50% but less than 75% of the space.
C) 1+: A 1+ tonsil grading refers to tonsils that are small and occupy less than 25% of the lateral dimension of the oropharynx. This would not be consistent with the findings described in the question, where the tonsils are larger and occupy a greater proportion of the oropharynx.
D) 4+: A 4+ tonsil grading indicates that the tonsils are extremely enlarged and occupy more than 75% of the lateral dimension of the oropharynx. This would be a much larger size than described in the question. Therefore, a 4+ grading is not appropriate here.
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