The nurse is caring for a patient who reports enlarged, painful, and moveable preauricular lymph nodes, postauricular lymph nodes, and cervical lymph nodes. Which does the nurse infer from these findings?
Liver Failure
Thyroid Disorder
Infection
Cancer
The Correct Answer is C
A. Liver Failure: Lymph node enlargement is not a typical finding in liver failure. Common signs of liver failure include jaundice and ascites.
B. Thyroid Disorder: Thyroid disorders typically present with changes in metabolism, thyroid enlargement (goiter), or thyroid hormone imbalances rather than lymphadenopathy.
C. Infection: Painful, movable lymph nodes are commonly associated with bacterial or viral infections.
D. Cancer: Cancer-related lymphadenopathy is typically painless and associated with firm, fixed lymph nodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Slow respirations: Tachypnea, not slow respirations, is more likely during a transfusion reaction.
B. Bradycardia: Tachycardia is more common due to the body's response to stress or inflammation.
C. Hypertension: Hypotension is more typical in severe reactions.
D. Fever/chills: Fever and chills are hallmark signs of febrile or hemolytic transfusion reactions due to the immune system's response to foreign antigens.
Correct Answer is B
Explanation
A. Prevents Rh antibodies in a newborn who is Rh-positive: The medication is not administered to newborns but to Rh-negative mothers.
B. Prevents the formation of Rh antibodies by a woman who is Rh-negative: Rho(D) immune globulin prevents maternal sensitization to Rh-positive fetal blood, avoiding hemolytic disease in future pregnancies.
C. Destroys Rh antibodies in a newborn who is Rh-positive: The goal is prevention in the mother, not antibody destruction in the newborn.
D. Destroys Rh antibodies in a woman who is Rh-negative: Rho(D) immune globulin does not destroy antibodies; it prevents their formation.
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