When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is:.
Infection or inflammation close to the site.
Some form of cancer.
Local scalp infection common in children.
Infection or inflammation distal to the site.
The Correct Answer is A
The correct answer is choice A. Infection or inflammation close to the site.
Choice A rationale:
Tender, enlarged, and warm lymph nodes are indicative of infection or inflammation in the nearby area. Lymph nodes are part of the immune system and can become enlarged and tender when fighting off infections in their drainage area.
Choice B rationale:
While cancer can cause lymph node enlargement, it is less likely in children, and the question doesn't provide any other context to suggest cancer as the primary explanation.
Choice C rationale:
Local scalp infection might cause enlargement of the lymph nodes in the neck, but it would not be the best explanation for tender, enlarged, and warm cervical lymph nodes. Infections or inflammation close to the site of lymph node involvement are more likely.
Choice D rationale:
Infection or inflammation distal to the site wouldn't directly explain the tenderness, warmth, and enlargement of the cervical lymph nodes. Lymph nodes generally react to infections or inflammation in their drainage area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answers are choices A, C, and D: Tachycardia, Hyperthermia, and Vomiting.
Choice A rationale:
Tachycardia. Tachycardia, an abnormally fast heart rate, is a classic manifestation of thyroid storm. In this life-threatening condition, there is an excessive release of thyroid hormones, leading to increased metabolic rate and subsequent cardiovascular effects such as tachycardia.
Choice B rationale:
Constipation. This choice is incorrect for thyroid storm. Hyperthyroidism typically leads to increased bowel motility and can cause diarrhea rather than constipation.
Choice C rationale:
Hyperthermia. This is a correct choice. Thyroid storm is associated with severe hyperthermia due to the increased metabolic rate caused by excessive thyroid hormones. The body's temperature regulation is disrupted, leading to dangerously high body temperatures.
Choice D rationale:
Vomiting. This is a correct choice. Gastrointestinal symptoms, including vomiting and nausea, can occur in thyroid storm due to the heightened metabolic state. Thyroid storm affects various systems, including the gastrointestinal system, leading to symptoms like vomiting.
Choice E rationale:
Hypotension. This choice is incorrect for thyroid storm. Thyroid storm is more likely to cause hypertension rather than hypotension due to the increased cardiac output and sympathetic stimulation.
Correct Answer is A
Explanation
The correct answer is choice A. Potassium.
Choice A rationale:
Diuretics like furosemide are commonly used to treat congestive heart failure. They work by increasing the excretion of water and electrolytes, including potassium, from the body. Low levels of potassium (hypokalemia) can lead to various complications, including cardiac arrhythmias and muscle weakness. Since furosemide can cause potassium loss, it's important to ensure an adequate intake of potassium-rich foods. Bananas, oranges, and leafy vegetables are excellent sources of potassium. Therefore, the nurse encourages the family to include these foods in the child's diet to help maintain a healthy potassium balance.
Choice B rationale:
Sodium is an important electrolyte, but in the context of congestive heart failure and diuretic use, the focus is more on avoiding excessive sodium intake. Diuretics like furosemide aim to reduce fluid retention by increasing sodium excretion, so it's not necessary to recommend high-sodium foods. Moreover, excessive sodium intake could exacerbate fluid retention and worsen the heart failure.
Choice C rationale:
Chlorides are often found in table salt (sodium chloride) and are not typically emphasized in the context of heart failure treatment or diuretic use. While they play a role in maintaining electrolyte balance, they are not the primary focus in this scenario.
Choice D rationale:
Zinc is a mineral that is not directly related to the treatment of congestive heart failure or the use of diuretics. It is important for various cellular functions and immune system support, but it's not the electrolyte of concern in this situation.
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