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

Auscultate the lymph node for the presence of a bruit.

Ask the client about any localized tenderness at the site.

Cover the inflamed area and notify the healthcare provider.

Record this normal finding in the assessment record.

Answer and Explanation

The Correct Answer is B

A. Auscultate the lymph node for the presence of a bruit.

Auscultating for a bruit over a lymph node may not be the most immediate or relevant action in this situation. While it could provide additional information about blood flow, it may not necessarily explain the cause of the enlarged lymph node.

B. Ask the client about any localized tenderness at the site.

This is an appropriate action. Localized tenderness at the site of an enlarged lymph node could indicate inflammation or infection. Gathering information about tenderness can help in understanding the possible cause of the lymphadenopathy.

C. Cover the inflamed area and notify the healthcare provider.

This is a reasonable action. Covering the inflamed area can help protect it from further irritation or infection. Notifying the healthcare provider is important because they can assess the lymph node, gather additional history, and determine if further evaluation or treatment is necessary.

D. Record this normal finding in the assessment record.

This option is incorrect. An enlarged, visible lymph node is not considered a normal finding. It could indicate underlying infection, inflammation, or another health issue. Recording it as a normal finding could lead to overlooking potential health concerns.

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Correct Answer is C

Explanation

A. Obtain a dietary consultation for nutrition teaching: Diet might play a role in some thyroid conditions, but a referral for dietary consultation wouldn't be the first step.

B. Instruct the client in the need to use iodized salt: Iodine deficiency can cause goiter (enlarged thyroid gland), but most table salt in developed countries is iodized.

C. Request diagnostic laboratory testing for the client: This is the most appropriate next step. Blood tests can help determine the cause of the enlarged thyroid gland.

D. Schedule a follow-up appointment in one month: A follow-up might be needed, but further workup is essential to determine the cause of the finding.

A. Mother's use of alcohol, drugs, or cigarettes during pregnancy. B. List of achievement timeline for developmental milestones. C. A history of rubella, rubeola, or chicken pox. D. Reactions to any previous hospitalizations.

Correct Answer is D

Explanation

A. Mother's use of alcohol, drugs, or cigarettes during pregnancy: While this information might be relevant to the child's medical history, it's not directly related to planning care for the umbilical hernia repair surgery itself.

B. List of achievement timeline for developmental milestones: This information might be helpful for a general paediatric assessment, but it's not crucial for planning care specific to an umbilical hernia repair.

C. A history of rubella, rubeola, or chicken pox: Unless there are complications related to these illnesses, they are not directly relevant to the surgery.

D. Reactions to any previous hospitalizations: This information is vital. Knowing how the child reacted to previous hospitalizations (anaesthesia, medications, separation anxiety) can help the nurse anticipate potential challenges and develop strategies to create a positive experience for the child.

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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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Naxlex Comprehensive Predictor Exams

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

Correct Answer is C

Explanation

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

Correct Answer is D

Explanation

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