The patient presents with fever for the last few days, sore throat and enlarged lymph nodes under the jaw. What is the appropriate response of the nurse when the patient asks about the cause of the enlarged lymph nodes?
Enlarged lymph nodes are associated with hypertensive heart disease."
"They are most likely enlarged as a result of the throat infection.
"You should probably see an oncologist to rule out lymphedema.
You probably have a blockage in the thoracic lymph duct"
The Correct Answer is B
A. Enlarged lymph nodes are associated with hypertensive heart disease is not a correct association. Hypertension does not directly cause lymph node enlargement.
B. They are most likely enlarged as a result of the throat infection is the correct answer. Enlarged lymph nodes, especially under the jaw, are commonly seen in response to infections, particularly in the throat (such as a viral or bacterial infection like pharyngitis).
C. You should probably see an oncologist to rule out lymphedema is an unnecessary response at this time. Lymphedema usually presents with other symptoms, and the patient's symptoms (fever, sore throat, and localized lymph node enlargement) suggest an infection rather than cancer.
D. You probably have a blockage in the thoracic lymph duct is not a common cause of localized lymph node enlargement. Blockages in the thoracic duct would affect lymphatic flow more generally and would present with more systemic symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The Jaeger card is typically used to assess near vision, not visual acuity at a distance, and would be more appropriate for an adult or someone with suspected near-vision issues.
B. The Snellen chart is used to assess distance visual acuity, and it is the standard tool for visual acuity testing for both adults and adolescents. The chart should be positioned 20 feet away from the patient to measure their ability to see at a distance.
C. Determining the ability to read newsprint is a test for near vision, not visual acuity for distance.
D. The confrontation test is a screening for peripheral vision, not for visual acuity.
Correct Answer is C
Explanation
A. While inserting a urinary catheter using aseptic technique is an important aspect of clinical care, it primarily focuses on maintaining hygiene and preventing infection rather than demonstrating the caring role.
B. Assessing the patient's entire health history is a critical nursing task but is more focused on gathering information rather than demonstrating the caring aspect.
C. Maintaining privacy when conversing with the patient shows respect for the patient’s dignity and confidentiality, which is a key demonstration of caring. It acknowledges the patient's need for emotional security and trust.
D. Administering antibiotic medications on time is part of ensuring the patient's treatment plan is followed but is more about medical responsibility than the specific expression of care.
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