When assessing lymph nodes on the face and neck, which of the following findings are concerning? Select all that apply.

Tender to the touch

Hard nodule

Measuring at 4 mm

Immovable

Non-palpable

Answer and Explanation

Correct Answer : B,D

A.   Tenderness in lymph nodes is not necessarily concerning. It may be due to inflammation or infection, which can cause the lymph nodes to be tender as they react to the presence of pathogens. Tenderness alone is not always indicative of a serious condition.
B.   A hard lymph node is concerning because it may suggest malignancy or a chronic infection. Hard, firm, and rubbery nodes can be associated with cancers, such as lymphoma or metastasis from other cancers. Therefore, hard lymph nodes should be evaluated further.
C.   Lymph nodes up to 1 cm (10 mm) can be considered normal, depending on the location and individual characteristics of the patient. A 4 mm lymph node is typically not concerning, especially if it is non- tender and mobile. Larger nodes, especially those over 1 cm, are more concerning.
D.   Lymph nodes that are immovable or fixed to surrounding tissues are concerning and may suggest malignancy. Cancerous nodes tend to be harder, larger, and fixed in place, which makes them less mobile. Any immovable lymph node requires further investigation.
E.   Non-palpable lymph nodes are normal and generally not a concern. Lymph nodes that are not palpable typically do not signify a problem, as they may be too small to be felt or located deep within the tissues.

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Correct Answer is B

Explanation

A. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pink and moist tympanic membrane is not a typical finding, as the tympanic membrane should be pearly gray.
B. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pearly gray tympanic membrane is the expected finding for a normal ear exam, showing the healthy tympanic membrane and the proper positioning of the cone of light.
C. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pink and moist tympanic membrane is incorrect, as the tympanic membrane should be pearly gray, not pink and moist.
D. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pearly gray tympanic membrane is an incorrect positioning of the cone of light (should be at 7 o'clock for the right ear and 5 o'clock for the left).

A. Pinnae of the ears B. Dorsal surface of the hand C. Dorsal surface of the foot D. Conjunctivae

Correct Answer is A

Explanation

A. Pinnae of the ears are one of the most reliable sites for detecting cyanosis in individuals with dark skin, as the color changes are more apparent in the mucous membranes and earlobes.
B. Dorsal surface of the hand may not reliably show cyanosis in darker skin tones, and it’s often less
visible.
C. Dorsal surface of the foot is not typically where cyanosis would be identified.
D. Conjunctivae can be used for detection in individuals with darker skin, but it is typically harder to visualize than the pinna.

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When assessing lymph nodes on the face and neck, which of the following findings are concerning? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is examining a patient's ears, which of the following findings is considered the expected findings?

Correct Answer is B

Explanation

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is A

Explanation

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