When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is:.
Infection or inflammation close to the site.
Some form of cancer.
Local scalp infection common in children.
Infection or inflammation distal to the site.
The Correct Answer is A
The correct answer is choice A. Infection or inflammation close to the site.
Choice A rationale:
Tender, enlarged, and warm lymph nodes are indicative of infection or inflammation in the nearby area. Lymph nodes are part of the immune system and can become enlarged and tender when fighting off infections in their drainage area.
Choice B rationale:
While cancer can cause lymph node enlargement, it is less likely in children, and the question doesn't provide any other context to suggest cancer as the primary explanation.
Choice C rationale:
Local scalp infection might cause enlargement of the lymph nodes in the neck, but it would not be the best explanation for tender, enlarged, and warm cervical lymph nodes. Infections or inflammation close to the site of lymph node involvement are more likely.
Choice D rationale:
Infection or inflammation distal to the site wouldn't directly explain the tenderness, warmth, and enlargement of the cervical lymph nodes. Lymph nodes generally react to infections or inflammation in their drainage area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Slowed growth.
Choice A rationale:
Slowed growth is a potential risk associated with long-term use of inhaled steroids in children with asthma. Inhaled steroids are a cornerstone of asthma management due to their anti-inflammatory effects on the airways, but they can have systemic effects when absorbed in larger amounts. Prolonged use of these steroids can potentially lead to growth suppression in children by affecting the normal growth and development of bones and other tissues.
Choice B rationale:
Osteoporosis is not the primary concern in children taking inhaled steroids. While long-term use of high-dose systemic steroids can lead to bone loss and osteoporosis in adults, the risk of osteoporosis is much lower in children receiving inhaled steroids for asthma management. Inhaled steroids have a lower systemic absorption, reducing the risk of significant bone density reduction in children.
Choice C rationale:
Cushing's syndrome is a condition caused by prolonged exposure to high levels of cortisol, often due to excessive use of systemic steroids. Inhaled steroids, especially at recommended doses, have a lower likelihood of causing Cushing's syndrome compared to systemic steroids. The systemic absorption of inhaled steroids is limited, minimizing the risk of this syndrome.
Choice D rationale:
Cough is not the primary increased risk associated with long-term use of inhaled steroids in children with asthma. Inhaled steroids are actually used to help control and prevent asthma symptoms, including cough. They work by reducing inflammation in the airways, which helps alleviate symptoms like coughing, wheezing, and shortness of breath.
Correct Answer is ["A","B","D"]
Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.
Choice B rationale:
Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.
Choice C rationale:
While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.
Choice D rationale:
Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.
Choice E rationale:
Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.
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