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. Report the client's abnormal lung sounds to the healthcare provider. B. Continue with the remainder of the client's physical assessment. C. Ask the client to cough and then auscultate at the site again. D. Measure the client's oxygen saturation with a pulse oximeter.

Correct Answer is B

Explanation

Choice A Reason:
Reporting the client's abnormal lung sounds to the healthcare provider is inappropriate. This option is not appropriate because vesicular breath sounds are actually normal lung sounds. They are soft, low-pitched sounds heard predominantly during inspiration in the peripheral lung fields. Reporting them as abnormal would be incorrect and could potentially lead to unnecessary concern or intervention.
Choice B Reason:
Continuing with the remainder of the client's physical assessment is appropriate. Vesicular breath sounds in the bases of both lungs posteriorly are normal findings. They indicate adequate ventilation and airflow in the lower lung fields. Therefore, there is no need for immediate intervention or further assessment specific to this finding. Continuing with the remainder of the physical assessment is appropriate to assess other aspects of the client's health.
Choice C Reason:
Asking the client to cough and then auscultate at the site again is inappropriate. Asking the client to cough and then auscultate again is not necessary in response to hearing vesicular breath sounds. Vesicular breath sounds are normal lung sounds and do not require further assessment or intervention. Coughing would not change the character of vesicular breath sounds.
Choice D Reason:
Measuring the client's oxygen saturation with a pulse oximeter is inappropriate. While measuring oxygen saturation with a pulse oximeter is an important assessment, it is not specifically indicated in response to hearing vesicular breath sounds. Vesicular breath sounds indicate normal ventilation and airflow in the lower lung fields, but they do not provide direct information about oxygenation status. Oxygen saturation should be assessed as part of a comprehensive respiratory assessment, but it does not need to be prioritized solely based on the finding of vesicular breath sounds.
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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

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?

Correct Answer is B

Explanation

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