The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

Nodes feel ropey and rubbery.

Axillary nodes feel soft and fatty.

Inguinal nodes are enlarged and warm to the touch.

Nodes are non-palpable.

Answer and Explanation

The Correct Answer is D

A. Lymph nodes that feel ropey and rubbery might indicate chronic inflammation or fibrosis. This texture is not typically considered normal. In elderly clients, lymph nodes may become less palpable due to age- related changes, but they should not feel ropey or rubbery. If lymph nodes feel this way, it may warrant further investigation to rule out pathological conditions.
B. In elderly clients, axillary lymph nodes may feel softer and less defined due to fatty tissue changes associated with aging. However, "soft and fatty" should be interpreted cautiously. While some degree of change is normal, nodes should not be excessively soft, nor should they have an abnormal appearance. The key is that they should not be hard, fixed, or tender, which would be indicative of pathology.
C. Enlarged and warm inguinal lymph nodes suggest infection or inflammation rather than a normal finding. In the elderly, while lymph nodes can sometimes be palpable, they should not be enlarged or warm, as this could indicate an underlying condition or infection that requires further evaluation.
D. It is normal for lymph nodes to be non-palpable in many individuals, including older adults. Age- related changes can cause lymph nodes to be less prominent or difficult to palpate. If lymph nodes are non-palpable, it usually means they are not enlarged or abnormal, which is a normal finding, especially if the client is not experiencing any symptoms of infection or other related issues.

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Correct Answer is A

Explanation

A. In the context of detecting papilledema, "inspection" refers to using an ophthalmoscope to examine the optic disc for swelling. Papilledema, which is swelling of the optic disc due to increased intracranial pressure, can only be observed through this direct examination of the eye’s interior. This technique is the most appropriate and accurate for confirming papilledema as it allows the nurse to visually inspect the optic disc for signs of swelling or other abnormalities.
B. Percussion involves tapping on the body to assess underlying structures and is commonly used in evaluating lung and abdominal sounds. It is not used for assessing the optic nerve or papilledema. Therefore, percussion is not relevant for confirming the presence of papilledema.
C. Palpation involves feeling the body’s surface to assess for abnormalities such as swelling or
tenderness. It is used for evaluating various parts of the body but does not apply to detecting papilledema. Papilledema involves changes to the optic nerve head, which cannot be assessed through palpation.
D. Auscultation involves listening to internal body sounds using a stethoscope, such as heartbeats, lung sounds, or abdominal sounds. This technique is not used to assess the optic disc or detect papilledema. It is not relevant for the diagnosis of conditions affecting the optic nerve.

A. Instruct the client to close both eyes. B. Cover the client with a warmed blanket. C. Darken the client's room environment. D. Measure the client's body temperature.

Correct Answer is A

Explanation

A. Instructing the client to close their eyes is crucial during sensory assessments, including temperature testing. This helps ensure that the client does not rely on visual cues to determine the temperature of
the stimuli, allowing the nurse to accurately assess the client’s sensory perception based purely on
touch and temperature differences.
B. Covering the client with a warmed blanket is not necessary for assessing temperature perception. This action could alter the client’s baseline sensory perception by affecting their skin temperature, which could lead to inaccurate results. The sensory assessment requires the client to experience temperature changes directly on their skin without external influences like additional warmth.
C. Darkening the room is not relevant for assessing temperature sensation. Visual impairment (like darkening the room) is not related to sensory nerve function related to temperature perception, and this step does not contribute to an accurate assessment of the client's ability to perceive temperature changes.
D. Measuring the client’s body temperature is not a direct method for assessing their sensory nerve function or temperature perception. While knowing the body temperature might be relevant for other reasons, it does not directly assess how well the client can sense temperature changes on their skin.

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The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Correct Answer is A

Explanation

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

Correct Answer is A

Explanation

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