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 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.

A. Potassium level B. Prealbumin/ level C. History of diabetes mellitus D. History of hyperlipidemia E. wound infection F. Decreased pedal perfusion G. Fasting blood glucose

Correct Answer is ["B","C","F"]

Explanation

A. The potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L), so there is no immediate concern. There is no abnormality in this lab value that needs to be addressed in this context.
B. The client's prealbumin level is 10 mg/dL, which is below the normal range (15 to 36 mg/dL). This is concerning as it indicates poor nutritional status, which can affect wound healing. Prealbumin is a sensitive indicator of nutritional status and is important in assessing the client's ability to heal from a pressure injury.
C. The client's history of diabetes mellitus is significant in this case. Diabetes can affect circulation, impair wound healing, and increase the risk of infections. Poor blood sugar control can contribute to delayed wound healing, so this is an important factor to consider.
D. While hyperlipidemia can contribute to cardiovascular issues, it is less directly related to wound healing in this case compared to diabetes mellitus. Although important to manage, it is not the most pressing issue in this context.

E. At this time, the wound shows no signs of infection. The surrounding skin is inflamed and red, which could be a sign of irritation or early pressure injury development, but there is no indication of infection (such as purulent drainage, increased pain, or fever) noted in the nursing notes.
F. The client's pedal pulse in the left foot is weak (1+), which indicates decreased perfusion to that extremity. Impaired circulation is a concern, especially in a client with diabetes, as it can further complicate wound healing. This is a critical factor to monitor closely.
G. The client's fasting blood glucose is elevated at 186 mg/dL, above the normal range (74 to 106 mg/dL). Elevated blood glucose levels can impair wound healing and increase the risk of infection, particularly in a client with diabetes.

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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

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

A nurse is caring for a client. Exhibits

Correct Answer is ["B","C","F"]

Explanation

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