The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?
In front of the ear.
In the midline, a few centimeters behind the tip of the mandible.
Superficial to the sternomastoid.
At the angle of the mandible.
The Correct Answer is B
Choice A reason:
Palpating in front of the ear would assess the preauricular lymph nodes, not the submental lymph nodes. The preauricular nodes are located just in front of the ears and are typically examined when there is an infection or inflammation in the eyes, ears, or scalp.
Choice B reason:
The submental lymph nodes are located in the midline, just under the chin, behind the bony prominence of the mandible. This is the correct area for palpation when assessing the submental lymph nodes. These nodes drain the lower lip, the floor of the mouth, the tip of the tongue, and the incisors, and they can become enlarged due to infections or malignancies in these areas.
Choice C reason:
Palpating superficial to the sternomastoid would assess the cervical lymph nodes, specifically the anterior cervical nodes, which are not the submental lymph nodes. The sternomastoid muscle is a landmark for several lymph node groups in the neck, but not for the submental group.
Choice D reason:
Palpating at the angle of the mandible would assess the submandibular lymph nodes, not the submental lymph nodes. The submandibular nodes are located beneath the jawline and can become enlarged due to infections or malignancies in the mouth, throat, and salivary glands.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a reason:
Eye malalignment is a general term that refers to any form of misalignment of the eyes, which can include esotropia but is not specific to it. Esotropia is a type of strabismus where there is a specific pattern of eye malalignment.
Choice b reason:
Eye turning outward is known as exotropia, which is the opposite of esotropia. In exotropia, one or both eyes turn outward away from the nose, which is not characteristic of esotropia.
Choice c reason:
Eye oscillating refers to nystagmus, a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception. While nystagmus can occur in conjunction with esotropia, it is not a defining characteristic of esotropia itself.
Choice d reason:
Eye turning inward is the hallmark of esotropia. In this condition, one or both eyes turn inward towards the nose. It can be constant or intermittent and may affect one eye or alternate between both eyes. Esotropia can be comitant, meaning the degree of deviation is the same in every direction of gaze, or incomitant, where the deviation varies with gaze direction.
Correct Answer is B
Explanation
Choice a reason:
Tympany is a drum-like, resonant sound that is typically heard over air-filled structures, such as the gastric bubble, not the chest. It is not a sound associated with the lungs, especially in the context of COPD.
Choice b reason:
Hyperresonance is an abnormally loud, lower-pitched sound than normal resonance heard over hyperinflated areas of the lung, such as in cases of COPD. This is due to the increased air content within the lungs, often because of overdistension or destruction of alveolar tissue, as seen in emphysema, a common type of COPD.
Choice c reason:
Resonance is the normal sound heard over healthy lung tissue when percussed. However, in the case of COPD, particularly emphysema, the destruction of lung tissue leads to hyperinflation and thus a hyperresonant sound rather than the normal resonance.
Choice d reason:
Dullness is heard when fluid or solid tissue replaces air in the lung or occupies the pleural space, as in the case of pneumonia or pleural effusion. This is not characteristic of COPD, where there is an increase in air due to the breakdown of alveolar walls.
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