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
Explanation
The correct answer is choice A: Avoiding use for more than 3 days.
Choice A rationale:
Recommending avoiding the use of decongestant nose drops for more than 3 days is crucial due to the risk of rebound congestion. Decongestant nose drops work by constricting blood vessels in the nasal passages to alleviate congestion. Prolonged use can lead to a phenomenon known as rebound congestion, where the nasal passages become more congested once the medication wears off, causing the person to use the drops more frequently. This can result in a cycle of worsening congestion and overuse of the medication, which can be counterproductive and harmful. Limiting the use of decongestant nose drops to 3 days helps prevent this rebound effect and encourages the use of alternative treatments if congestion persists.
Choice B rationale:
Administering drops until nasal congestion subsides is not the recommended approach. Prolonged use of decongestant nose drops can lead to rebound congestion, as mentioned earlier. Using the drops until congestion subsides might extend their use beyond the safe period and increase the risk of adverse effects.
Choice C rationale:
Keeping drops to use again for nasal congestion is not advised. While it's important to follow the medication's storage instructions, relying on decongestant nose drops for recurring nasal congestion can lead to overuse and rebound congestion. This choice does not address the potential risks associated with prolonged use.
Choice D rationale:
Administering drops after feedings and at bedtime is not a standard recommendation for decongestant nose drops. The timing of administration is not a primary concern in the context of decongestant use. Instead, the focus should be on the duration of use and the potential for rebound congestion.
Correct Answer is A
Explanation
The correct answer is choice A. The cuff bladder covers 50% to 66% of the length of the upper arm.
Choice A rationale:
Selecting a blood pressure cuff with a bladder that covers 50% to 66% of the length of the upper arm is the appropriate criterion for determining the cuff size for a 2-year-old boy. This range ensures accurate blood pressure measurement by ensuring a proper fit on the arm. If the cuff bladder is too small or too large, it can result in inaccurate readings.
Choice B rationale:
The label "toddler" on the cuff might be helpful in identifying the intended age group, but it doesn't provide precise measurements for cuff sizing. Relying solely on a label might not account for variations in arm sizes within the toddler age group.
Choice C rationale:
The cuff bladder width being 40% of the circumference of the upper arm might not be as accurate as the length-based criterion. A cuff that fits the arm's length is more critical in ensuring proper inflation and accurate blood pressure measurement.
Choice D rationale:
The cuff bladder length covering 80% to 100% of the circumference of the upper arm might result in an excessively large cuff for a 2-year-old, which can lead to inaccurate readings. Length-based sizing is more appropriate for accuracy in this scenario.
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