The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. When palpating the nodes on this patient, how would the lymph nodes feel?
Fixed
Rubbery, discrete, and mobile
Nonpalpable
Large, firm, and fixed to the tissue
The Correct Answer is B
A. Fixed lymph nodes are typically indicative of infection or malignancy. Healthy nodes are not fixed to the surrounding tissue.
B. Healthy lymph nodes are usually discrete (distinct and separated from surrounding tissue), mobile (moveable), and have a rubbery consistency. These are normal findings in a healthy patient.
C. Nonpalpable lymph nodes are normal and often not felt during an exam, especially if they are small or deeply located.
D. Large, firm, and fixed lymph nodes could be a sign of infection or a more serious condition such as cancer and would not be typical in a healthy patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Determine the patient's educational background and learning abilities is important but should be addressed after assessing the patient's comfort level. It is crucial to first ensure that the patient feels comfortable with the new colostomy before moving forward with further education.
B. Have the patient watch a video that demonstrates how to perform colostomy care may be useful, but it’s important to first assess the patient's emotional readiness to learn and their comfort level with the procedure.
C. Assess the patient's level of comfort with looking at and caring for the colostomy is the correct first step. It’s essential to first assess how the patient feels about the colostomy and determine any emotional or psychological barriers that might need to be addressed before teaching the technical aspects of care.
D. Identify a responsible family member to reinforce colostomy care teaching is important, but the first action should focus on the patient’s readiness and comfort with performing the care themselves.
Correct Answer is B
Explanation
A. Lecture is a more formal, one-way method of instruction where the nurse teaches the patient, but it doesn't provide the same level of interactive support as a group discussion.
B. Group Discussion allows patients to share experiences, ask questions, and receive support from others in the group. It creates an environment where patients can learn from each other and feel supported by their peers.
C. Return Demonstration involves the patient demonstrating a skill after it has been taught, but it doesn't provide the group support that a discussion would.
D. One On One Discussion is a more individualized approach, which doesn't offer the benefit of support from multiple people like a group discussion would.
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