The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Cover the inflamed area and notify the healthcare provider.

Auscultate the lymph node for the presence of a bruit.

Ask the client about any localized tenderness at the site.

Record this normal finding in the assessment record.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Covering the inflamed area and notify the healthcare provider suggests taking precautions to protect the inflamed area and promptly informing the healthcare provider. While it's important to notify the healthcare provider about any concerning findings, covering the area without further assessment may prevent the nurse from gathering additional information that could be helpful in determining the cause of the lymph node enlargement.
Choice B Reason:
Auscultating the lymph node for the presence of a bruit involves listening for abnormal sounds (bruits) over the lymph node, which could indicate underlying vascular abnormalities. While it's important to assess lymph nodes for abnormalities, such as tenderness or enlargement, auscultation for bruits is not a standard assessment technique for lymph nodes.
Choice C Reason:
Asking the client about any localized tenderness at the site involves directly gathering information from the client about their experience of tenderness at the site of the enlarged lymph node. This information can provide valuable clues about the nature of the lymph node enlargement, such as whether it is inflamed due to infection or inflammation.
Choice D Reason:
Recording this normal finding in the assessment record assumes that the nurse considers the enlarged and visible lymph node as a normal finding. However, enlarged and visible lymph nodes are not typically considered normal and may indicate an underlying health issue that requires further assessment and intervention.

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Correct Answer is B

Explanation

Choice A Reason:
Splint the affected joint is inappropriate action. While splinting may help stabilize the joint and reduce movement, it may not directly address the underlying cause of the symptoms, which is9levated uric acid levels leading to gout. Additionally, splinting may further restrict range of motion and exacerbate discomfort.
Choice B Reason:
Encouraging fluid intake is appropriate action. Encouraging fluid intake, particularly water, is beneficial for individuals experiencing a gout flare-up. Adequate hydration helps to dilute uric acid in the bloodstream and promote its excretion through urine, which can help alleviate symptoms and prevent further flare-ups. Therefore, option B is the most appropriate action for the nurse to advise the client in this situation.
Choice C Reason:
Increasing intake of red meat is inappropriate action. Red meat is high in purines, which can contribute to elevated uric acid levels and increase the risk of gout flare-ups. Therefore, increasing intake of red meat would not be advisable for someone experiencing gout symptoms. In fact, dietary modifications often involve reducing intake of purine-rich foods like red meat to help manage gout.
Choice D Reason:
Measuring urine output is inappropriate action. While monitoring urine output is important for overall hydration status, it may not be the most immediate or relevant action in this situation. The priority in managing a gout flare-up is to address the underlying cause by promoting uric acid excretion through adequate hydration, rather than solely focusing on measuring urine output.

A. “ever had problems with your blood sugar?" B. “been sleeping well? C. “ had anything to eat in the last 24 hours? D. “been depressed lately?

Correct Answer is B

Explanation

Choice A Reason:
Blood sugar levels can impact neurological function, leading to symptoms like slurred speech, but this is less likely to be the immediate cause of the expressionless affect and red conjunctivae. While important, this question may not address the most urgent concern first. client's symptoms.

Choice B Reason:
"Been sleeping well?" Poor sleep could contribute to slurred speech and an expressionless affect. Asking about sleep might help identify if sleep deprivation is contributing to the symptoms.
Choice C Reason:
Not eating could lead to hypoglycemia, which might cause slurred speech, but it is less likely to explain the red conjunctivae and expressionless affect. This question is important but might not address the immediate cause of the symptoms.
Choice D Reason:
Depression could lead to an expressionless facial affect, but it is less likely to explain slurred speech and red conjunctivae. This question addresses one possible cause but doesn't cover the immediate physical symptoms.

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The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

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