The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Cover the inflamed area and notify the healthcare provider.

Auscultate the lymph node for the presence of a bruit.

Ask the client about any localized tenderness at the site.

Record this normal finding in the assessment record.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is A

Explanation

Choice A Reason:
Palpating the client's dorsalis pedis pulses is appropriate because shiny lower legs with no hair growth are characteristic findings of peripheral arterial disease (PAD), which commonly occurs in individuals with diabetes mellitus. Palpating the client's dorsalis pedis pulses allows the nurse to assess peripheral arterial perfusion. Weak or absent dorsalis pedis pulses may indicate decreased blood flow to the feet and lower extremities, supporting the diagnosis of PAD.
Choice B Reason:
Asking if the client often feels weak or hungry is less relevant to the assessment findings of shiny lower legs with no hair growth. While it is important to assess for symptoms of hypoglycemia in clients with diabetes mellitus, such as weakness or hunger, these symptoms do not directly correlate with the observed peripheral vascular changes.
Choice C Reason:
Comparing the range of motion of both legs is less relevant to the assessment findings of shiny lower legs with no hair growth. Range of motion assessment is important for assessing joint function and mobility but does not provide information specifically related to peripheral vascular status.
Choice D Reason:
Measuring the client's capillary glucose is less relevant to the assessment findings of shiny lower legs with no hair growth. While it is important to monitor blood glucose levels in clients with diabetes mellitus, capillary glucose measurement does not provide information specifically related to peripheral vascular status or the observed findings of PAD.

A. Ask about recent abdominal trauma. B. Palpate the area for masses. C. Document the normal finding. D. Observe the midline for scarring.

Correct Answer is C

Explanation

Choice A Reason:

Ask about recent abdominal trauma: in this case, the depressed umbilicus is a normal finding, so no further action related to trauma assessment is necessary.

Choice B Reason:

Palpate the area for masses: Palpating the area for masses is a good practice during abdominal assessments. However, in the context of a depressed umbilicus, this finding is not indicative of an abnormal mass. Therefore, palpation is not specifically warranted.

Choice C Reason:

Document the normal finding: Correct! A depressed umbilicus that lies below the surface of the abdomen is considered a normal variation. Documenting this finding ensures accurate and comprehensive assessment documentation.

Choice D Reason:

Observe the midline for scarring: While observing the midline for scarring is relevant in some situations (such as assessing for surgical scars), it’s not directly related to the depressed umbilicus. Therefore, this action is not necessary based on the specific finding described.

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The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

The nurse observes that the lower legs of a client with diabetes mellitus are shiny with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Correct Answer is A

Explanation

During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse take in response to this observation?

Correct Answer is C

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?