An adult patient visits the clinic expressing concern about a lump that appeared on their neck about a week ago.
Upon examination, the nurse finds a large, non-tender, hardened left subclavian lymph node without any overlying tissue inflammation.
What could these findings indicate?
Malignancy
Bacterial infection
Viral infection
Lymphangitis .
The Correct Answer is A
Choice A rationale
A large, non-tender, hardened lymph node without overlying tissue inflammation could indicate malignancy. Lymph nodes may become enlarged or hard due to the presence of cancer cells.
Choice B rationale
While bacterial infections can cause lymph node enlargement, they typically also cause tenderness and overlying skin changes, such as redness or warmth.
Choice C rationale
Viral infections can cause generalized lymph node enlargement, but the nodes are usually tender and not hard.
Choice D rationale
Lymphangitis, or inflammation of the lymphatic channels, typically presents with red streaks on the skin, fever, and tenderness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While regular monitoring of blood sugar levels is important in managing diabetes, checking every four to six hours every day may not be necessary for all patients. The frequency of blood glucose monitoring should be individualized based on the type and severity of the diabetes, the patient’s blood glucose control, and the patient’s specific needs.
Choice B rationale
Keeping diabetic medication on schedule as prescribed is crucial in managing blood glucose levels and preventing complications related to diabetes. This indicates that the patient has understood the importance of medication adherence in diabetes management.
Choice C rationale
While it’s recommended to limit alcohol consumption, restricting alcoholic beverages to no more than 1-2 per week is not a standard guideline for all patients with diabetes. The effects of alcohol on blood glucose levels can vary depending on several factors, including the amount of alcohol consumed, the presence of food, and the individual’s overall diabetes management.
Choice D rationale
Limiting daily fat intake to 15% of total calories is not a standard recommendation for patients with diabetes. The American Diabetes Association recommends individualized medical nutrition therapy to manage diabetes, which may include monitoring carbohydrate intake and considering the quality of fats and proteins in the diet.
Correct Answer is D
Explanation
Choice A rationale
While a case management evaluation of the client’s home environment could potentially identify areas for improvement, it may not directly address the caregiver’s immediate need for relief from their caregiving responsibilities. The caregiver is experiencing sleepless nights and frequent bouts of crying, which could be signs of caregiver burnout or depression. Therefore, immediate respite care may be more beneficial.
Choice B rationale
Employing a private duty nurse for respite could provide temporary relief for the caregiver. However, this option might not be feasible due to potential financial constraints. Additionally, it may not provide the caregiver with the emotional support they may need.
Choice C rationale
Proposing that extended family could relocate to the area to provide support is a potential long-term solution. However, it may not be feasible or practical for extended family members to relocate. This option also does not address the caregiver’s immediate need for relief and support.
Choice D rationale
Advising the caregiver to contact social services to locate a respite care facility for the client could provide the caregiver with the immediate relief they need. Respite care facilities offer temporary relief for caregivers by providing short-term care for the individual they are caring for. This would allow the caregiver to rest and take care of their own needs, which could help alleviate their symptoms of sleepless nights and frequent bouts of crying.
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