During an admission assessment of a client, the nurse palpates enlarged axillary lymph nodes. Which question should the nurse ask the client related to this finding?

Do you have a history of cardiac disease?

Have you had a recent infection?

Are you having any shortness of breath?

Have you had surgery on your neck?

Answer and Explanation

The Correct Answer is B

Choice A reason: A history of cardiac disease is not directly related to enlarged axillary lymph nodes. Cardiac disease may affect the heart, blood vessels, and circulation, but not the lymphatic system. ¹

Choice B reason: A recent infection is a possible cause of enlarged axillary lymph nodes. Lymph nodes are part of the immune system and they swell when they are fighting an infection. ² The nurse should ask the client about any signs or symptoms of infection, such as fever, sore throat, or skin rash.

Choice C reason: Shortness of breath is not directly related to enlarged axillary lymph nodes. Shortness of breath may indicate a respiratory problem, such as asthma, bronchitis, or pneumonia. ³ However, these conditions do not usually affect the lymph nodes in the armpit area.

Choice D reason: Surgery on the neck is not directly related to enlarged axillary lymph nodes. Surgery on the neck may affect the lymph nodes in the neck or the collarbone area, but not the lymph nodes in the armpit area. The nurse should ask the client about any history of surgery or trauma to the lymph nodes or the surrounding tissues.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. Walking directly in front of the client may block their view and increase their risk of falling. The nurse should walk to the side and slightly behind the client to provide support and guidance³.

Choice B reason: This is correct. Walking along the affected left side allows the nurse to assist the client with balance, weight shifting, and foot clearance. The nurse should also encourage the client to use the handrail on their strong side³.

Choice C reason: This is incorrect. Walking directly behind the client may not allow the nurse to see the client's gait pattern or intervene quickly if the client loses balance. The nurse should walk to the side and slightly behind the client to monitor and assist them³.

Choice D reason: This is incorrect. Walking along the unaffected right side may not provide adequate support or protection for the client's affected side. The nurse should walk along the affected left side to help the client with their hemiplegic gait³.

A. Place a pad under the buttocks B. Check the rectal area for soiling frequently C. Wash the buttocks with strong soap and water D. Place the call bell in the client's reach

Correct Answer is B

Explanation

Choice A reason: Placing a pad under the buttocks is not the best intervention to help prevent skin breakdown. A pad can absorb some of the moisture and protect the bed linen, but it can also trap heat and bacteria and cause irritation and infection of the skin.

Choice B reason: This is the best intervention to help prevent skin breakdown. Checking the rectal area for soiling frequently allows the nurse to remove any fecal matter and clean the skin as soon as possible. This reduces the exposure of the skin to moisture, acidity, and enzymes that can damage the skin integrity and cause inflammation and ulceration.

Choice C reason: Washing the buttocks with strong soap and water is not the best intervention to help prevent skin breakdown. Strong soap can strip the natural oils and protective barrier of the skin and make it more vulnerable to injury and infection. The nurse should use mild soap and water or a pH-balanced cleanser and pat the skin dry gently.

Choice D reason: Placing the call bell in the client's reach is not the best intervention to help prevent skin breakdown. A mentally impaired client may not be able to use the call bell or communicate their needs effectively. The nurse should not rely on the client's ability to ask for help, but rather check on the client regularly and provide appropriate care.

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During an admission assessment of a client, the nurse palpates enlarged axillary lymph nodes. Which question should the nurse ask the client related to this finding?

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