A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Choice A Reason:
Covering the inflamed area and notify the healthcare provider suggests taking precautions to protect the inflamed area and promptly informing the healthcare provider. While it's important to notify the healthcare provider about any concerning findings, covering the area without further assessment may prevent the nurse from gathering additional information that could be helpful in determining the cause of the lymph node enlargement.
Choice B Reason:
Auscultating the lymph node for the presence of a bruit involves listening for abnormal sounds (bruits) over the lymph node, which could indicate underlying vascular abnormalities. While it's important to assess lymph nodes for abnormalities, such as tenderness or enlargement, auscultation for bruits is not a standard assessment technique for lymph nodes.
Choice C Reason:
Asking the client about any localized tenderness at the site involves directly gathering information from the client about their experience of tenderness at the site of the enlarged lymph node. This information can provide valuable clues about the nature of the lymph node enlargement, such as whether it is inflamed due to infection or inflammation.
Choice D Reason:
Recording this normal finding in the assessment record assumes that the nurse considers the enlarged and visible lymph node as a normal finding. However, enlarged and visible lymph nodes are not typically considered normal and may indicate an underlying health issue that requires further assessment and intervention.

Choice A Reason:
Normal mental status for age is incorrect. This choice would not be the most accurate conclusion based on the client's response. While it's possible that the client's response could be influenced by factors such as cultural background or personal interpretation, the inability to understand the metaphorical meaning of a commonly known proverb might suggest some level of cognitive impairment or difficulty with abstract thinking. Therefore, it would be premature to conclude that the client's response reflects a normal mental status for her age.
Choice B Reason:
Impaired concentration is incorrect. Impaired concentration would manifest as difficulty maintaining focus our attention during the interaction. However, the client's response doesn't suggest a lack of attention or focus. Instead, it indicates a misinterpretation of the proverb, which is more indicative of impaired thinking or difficulty understanding abstract concepts rather than impaired concentration.
Choice C Reason:
Impaired memory is incorrect. Impaired memory would typically involve difficulty recalling information or events from the past. In this scenario, the client is able to recall the phrase "Glass Houses" but demonstrates difficulty understanding its meaning. Therefore, impaired memory is not the most appropriate conclusion based on the client's response. Instead, the response suggests impaired thinking or difficulty with abstract reasoning.
Choice D Reason:
Impaired thinking is correct. The client's response indicates difficulty understanding the metaphorical meaning of the proverb "Glass Houses," which typically implies that those who live in fragile or vulnerable situations should avoid criticizing others, as they themselves are also vulnerable to criticism or judgment. Instead, the client's response focuses on the literal interpretation of the phrase, suggesting impaired thinking or difficulty grasping abstract concepts.