An adult client comes to the clinic and reports concern over a lump that, "Just popped up on my neck about a week ago." While performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. Which of these findings suggest?
Lymphangitis.
Malignancy.
Viral Infection.
Bacterial Infection.
The Correct Answer is B
A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.
B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.
C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.
D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fluid volume deficit. Gastroenteritis, characterized by fever, chills, anorexia, and diarrhea, can lead to significant fluid loss, especially in an older adult who may already have compromised fluid balance due to other factors such as stroke-related immobility. Fluid volume deficit is a critical problem that requires immediate attention to prevent complications such as hypovolemic shock.
B. Bowel incontinence. While bowel incontinence is a concern, it is not as immediately life- threatening as fluid volume deficit.
C. Caregiver role strain. While important for the client's overall well-being, caregiver role strain is a secondary concern compared to the client's physiological needs.
D. Impaired bed mobility. Impaired bed mobility is a long-term issue that requires attention but is not as urgent as addressing the immediate physiological needs of fluid volume deficit.
Correct Answer is D
Explanation
A. Resume antithyroid drug therapy.
Antithyroid medications are typically not resumed immediately post-thyroidectomy unless specifically directed by the healthcare provider. The focus post-surgery is often on managing potential complications and ensuring proper healing.
B. Anticipate and monitor for hypothermia.
Hypothermia is not a common concern following thyroidectomy. The nurse should monitor for other more relevant complications such as bleeding, airway obstruction, and hypocalcemia.
C. Prepare to administer radioactive iodine treatments.
Radioactive iodine treatment is usually not administered immediately post-thyroidectomy. It may be considered later, depending on the reason for the thyroidectomy and the individual treatment plan.
D. Maintain a semi-Fowler position.
This is the correct intervention. Maintaining the client in a semi-Fowler position helps reduce strain on the surgical site, facilitates breathing, and minimizes the risk of complications such as bleeding and edema in the neck area. It is an essential part of postoperative care for
thyroidectomy patients.
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