The nurse has just completed a lymph assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
not palpable
large, firm, and fixed to the tissue
rubbery, discrete, and mobile
shotty
The Correct Answer is A
A. not palpable: In healthy adults, most lymph nodes are not palpable because they are small and embedded within surrounding tissues. Palpable nodes often indicate infection, inflammation, or malignancy, making non-palpable nodes the expected finding.
B. large, firm, and fixed to the tissue: Large, fixed, and firm lymph nodes are concerning for malignancy or chronic disease. These characteristics are abnormal and require further investigation, not a normal finding in a healthy adult.
C. rubbery, discrete, and mobile: Rubbery, mobile lymph nodes can be seen in conditions such as lymphoma or after infections. While mobility is less concerning, rubbery enlargement is not considered a normal feature in a healthy individual.
D. shotty: Shotty nodes feel like small beads under the skin and are often associated with past or resolved infections. While sometimes benign, they are not the expected finding in a healthy adult without underlying pathology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. pulsations of the inferior vena cava: The inferior vena cava returns deoxygenated blood to the heart and does not typically create visible pulsations on abdominal inspection. Its flow is low pressure, making it unlikely to generate the observed movement.
B. normal abdominal aortic pulsations: The abdominal aorta lies midline between the xiphoid process and umbilicus, and mild pulsations can often be seen in thin individuals. These visible movements are usually normal and reflect the forward flow of blood through the aorta.
C. increased peristalsis from a bowel obstruction: Bowel obstruction may cause visible peristaltic waves across the abdomen, but these movements are more lateral and wave-like rather than rhythmic pulsations. They are not confined to the midline region.
D. pulsations of the renal arteries: The renal arteries branch off laterally from the abdominal aorta and are not visible as midline pulsations. They supply blood directly to the kidneys and do not produce surface movements detectable on inspection.
Correct Answer is C
Explanation
A. Once the speculum is in the ear, release the traction: Traction on the pinna should be maintained throughout the examination to keep the ear canal straight. Releasing it too soon may obstruct visualization of the tympanic membrane.
B. Use the smallest speculum to decrease the amount of discomfort: The largest speculum that comfortably fits should be used to allow better illumination and visualization. A very small speculum limits the field of view and may compromise accuracy of the assessment.
C. Pull the pinna up and back before inserting the speculum: For adults, pulling the pinna up and back helps straighten the ear canal, making it easier to insert the otoscope and visualize internal structures. This is the correct method for adult ear examination.
D. Tilt the person's head forward during the examination: Tilting the head is not necessary for an otoscopic exam in adults. The essential technique is proper traction on the pinna, not repositioning of the entire head.
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