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 C

Explanation

A. Confluent lesions merge together, forming a larger area of affected skin, which is not the case here.
B. Discrete lesions are separate and distinct from each other, which doesn't match the description of clusters.
C. Grouped lesions are those that appear in clusters, which fits the assessment finding.
D. Annular lesions have a ring-like appearance, typically seen in conditions like ringworm, and do not fit the description of clustered lesions.

A. Exposed bone B. Blood filled blisters C. Necrotic subcutaneous tissue D. Partial-thickness skin loss

Correct Answer is C

Explanation

A. Exposed bone refers to a stage 4 pressure ulcer, which involves full-thickness tissue loss with bone, muscle, or tendon exposure.
B. Blood-filled blisters are more indicative of a stage 2 ulcer, which involves partial-thickness skin loss with blister formation.

C. A stage 3 ulcer is characterized by full-thickness skin loss, with damage extending into subcutaneous tissue, where necrosis may occur.
D. Partial-thickness skin loss is a characteristic of a stage 2 pressure ulcer, not stage 3.

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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

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Correct Answer is C

Explanation

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