When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm.
The best explanation for this is.
some form of cancer.
local scalp infection common in children.
infection or inflammation distal to the site.
infection or inflammation close to the site.
The Correct Answer is D
Choice A rationale:
Some form of cancer. Rationale: Tender, enlarged, and warm cervical lymph nodes are indicative of infection or inflammation close to the site. Cancerous lymph nodes are usually painless and firm. In this case, the symptoms suggest an active immune response to infection or inflammation in proximity to the palpated lymph nodes.
Choice B rationale:
Local scalp infection common in children. Rationale: Local scalp infection, while possible, typically does not cause tender, enlarged, and warm cervical lymph nodes. These symptoms are more consistent with an active immune response to infection or inflammation in the area near the lymph nodes.
Choice C rationale:
Infection or inflammation distal to the site. Rationale: Symptoms such as tenderness, enlargement, and warmth in cervical lymph nodes indicate a local response to infection or inflammation close to the site. "Distal" refers to a location away from the affected area, making this choice inappropriate for the described symptoms.
Choice D rationale:
Infection or inflammation close to the site. Rationale: Tender, enlarged, and warm cervical lymph nodes suggest an active immune response to infection or inflammation in the vicinity. These symptoms are signs of localized inflammation and are commonly seen in conditions such as tonsillitis, pharyngitis, or other upper respiratory infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ribbon-like stools are more characteristic of conditions like irritable bowel syndrome (IBS) or colorectal cancer, not intussusception. Intussusception is a medical emergency where one segment of the intestine telescopes into another, leading to obstruction and potentially compromised blood flow.
Choice B rationale:
Hard stools positive for guaiac are suggestive of constipation and are not specific to intussusception. In intussusception, the stool characteristics are usually not relevant to the diagnosis as the condition primarily involves intestinal obstruction.
Choice C rationale:
"Currant jelly" stools are a classic characteristic of intussusception. These stools contain mucus and blood and have a characteristic appearance due to the compromised blood flow and tissue damage in the intestines. Recognizing this stool description is crucial for identifying a potential case of intussusception.
Choice D rationale:
Loose, foul-smelling stools are not specific to intussusception. These symptoms could be indicative of various gastrointestinal issues but are not directly associated with the classic presentation of intussusception, which involves the passage of bloody mucus in the stool.
Correct Answer is A
Explanation
Choice A rationale:
It is a belief common at this age. Rationale: The child's belief that she has cancer because God is punishing her for "being bad" and her fear of going to hell if she dies is consistent with magical thinking, which is common in children around the age of 8. Children at this age often have difficulty understanding cause and effect relationships, leading to magical or illogical thinking patterns. It is essential for the nurse to recognize this developmental aspect and respond empathetically and supportively.
Choice B rationale:
Choice C rationale:
The belief is suggestive of excessive family pressure. Rationale: There is no evidence in the scenario to suggest that the child's belief is related to family pressure. The child's statements are more consistent with age-appropriate magical thinking and fear related to concepts of punishment and the afterlife.
Choice D rationale:
The statement suggests a failed attempt to develop a conscience. Rationale: The child's belief does not indicate a failed attempt to develop a conscience. Instead, it reflects a typical developmental stage where children often have magical thoughts and fears. This stage is temporary and part of normal cognitive development.
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