At which location would a nurse palpate a client's occipital lymph nodes?

At the angle of the mandible

temporal area

The posterior base of the skull

Area in front of the ears

Answer and Explanation

The Correct Answer is C

A) At the angle of the mandible:

Lymph nodes located at the angle of the mandible are the submandibular lymph nodes, not the occipital lymph nodes. These nodes are situated below the jawline and are assessed when looking for infections or abnormalities in the oral cavity and throat.

B) Temporal area:

The temporal area is not a typical location for lymph node palpation. This region is primarily related to the temporal artery and muscles, not to lymph nodes. Thus, palpating for lymph nodes here would not be relevant.

C) The posterior base of the skull:

The occipital lymph nodes are located at the posterior base of the skull, near the nape of the neck. These nodes drain the scalp and are assessed when there are scalp infections or other related conditions.

D) Area in front of the ears:

The lymph nodes in front of the ears are the preauricular lymph nodes. These nodes drain the eyes and the surrounding skin. They are not the occipital lymph nodes, which are situated at the back of the head.

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Correct Answer is C

Explanation

A. Measure nerve function in the fingers:

Measuring nerve function typically involves different assessments, such as checking sensation or performing nerve conduction studies. The action in the image is not indicative of a nerve function test.

B. Monitor oxygen status:

Monitoring oxygen status is usually done with a pulse oximeter, which is placed on the finger but does not involve the manual action shown in the image. The image depicts a manual technique, not a pulse oximetry procedure.

C. Determine capillary refill:

The action shown in the image is a technique used to determine capillary refill time. The nurse presses on the nail bed until it blanches and then releases it to see how quickly the color returns. This assesses peripheral perfusion and can indicate circulatory status.

D. Assess finger range of motion:

Assessing finger range of motion involves moving the fingers through their full range of motion, such as flexing, extending, abducting, and adducting them. The action in the image does not reflect these movements and is more indicative of assessing capillary refill.

A. Stage I B. Stage III C. Stage IV D. Stage II

Correct Answer is D

Explanation

Stage I: Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin. There is no break in the skin, but it may appear red and warm to the touch. It is considered the mildest form of pressure injury, signaling the beginning of potential skin damage.

B) Stage III: Stage III pressure ulcers involve full-thickness skin loss. This means that the damage extends through the dermis into the subcutaneous tissue. There may be visible fat, but bone, tendon, and muscle are not exposed. These ulcers are deeper and more serious than the scenario described.

C) Stage IV: Stage IV pressure ulcers are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. The presence of slough or eschar may be present on some parts of the wound bed, and these ulcers are deep, often with extensive damage and infection.

D) Stage II: Stage II pressure ulcers are characterized by partial-thickness skin loss involving the epidermis and/or dermis. They present as shallow, open ulcers with a red-pink wound bed, without slough. They may also appear as intact or open/ruptured serum-filled blisters, which matches the description given in the scenario. This stage represents a more significant injury than Stage I but does not extend into the deeper layers of skin and tissue as in Stage III and IV.

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At which location would a nurse palpate a client's occipital lymph nodes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment the nurse performs the action shown in this image. What is the purpose of this action?

Correct Answer is C

Explanation

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

Correct Answer is D

Explanation

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