When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm.
The best explanation for this is.
some form of cancer.
local scalp infection common in children.
infection or inflammation distal to the site.
infection or inflammation close to the site.
The Correct Answer is D
Choice A rationale:
Some form of cancer. Rationale: Tender, enlarged, and warm cervical lymph nodes are indicative of infection or inflammation close to the site. Cancerous lymph nodes are usually painless and firm. In this case, the symptoms suggest an active immune response to infection or inflammation in proximity to the palpated lymph nodes.
Choice B rationale:
Local scalp infection common in children. Rationale: Local scalp infection, while possible, typically does not cause tender, enlarged, and warm cervical lymph nodes. These symptoms are more consistent with an active immune response to infection or inflammation in the area near the lymph nodes.
Choice C rationale:
Infection or inflammation distal to the site. Rationale: Symptoms such as tenderness, enlargement, and warmth in cervical lymph nodes indicate a local response to infection or inflammation close to the site. "Distal" refers to a location away from the affected area, making this choice inappropriate for the described symptoms.
Choice D rationale:
Infection or inflammation close to the site. Rationale: Tender, enlarged, and warm cervical lymph nodes suggest an active immune response to infection or inflammation in the vicinity. These symptoms are signs of localized inflammation and are commonly seen in conditions such as tonsillitis, pharyngitis, or other upper respiratory infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A respiratory rate of 10 bpm is significantly lower than the normal range for adults, which is typically 12-20 breaths per minute. This finding suggests respiratory depression, a potential complication of magnesium sulfate administration. Magnesium sulfate, when given intravenously, can lead to respiratory depression, hypotension, and loss of deep tendon reflexes. Monitoring respiratory rate is crucial to detect early signs of respiratory depression, allowing prompt intervention to prevent respiratory failure.
Choice B rationale:
A blood pressure of 148/94 mmHg is elevated and indicates hypertension. While hypertension is a known side effect of magnesium sulfate, a blood pressure reading alone is not specific enough to indicate a complication of treatment. It is essential to consider other vital signs and symptoms for a comprehensive assessment.
Choice C rationale:
Deep tendon reflexes of +2 are within the normal range and do not indicate a complication of magnesium sulfate administration. Hyperreflexia (exaggerated reflexes) is a sign of magnesium toxicity, but +2 reflexes are normal. Monitoring deep tendon reflexes is crucial, but the given value is within the normal range.
Choice D rationale:
An urine output of 70 ml/hour is within the normal range of urine output (30-60 ml/hour) for adults. While monitoring urine output is essential to assess renal function, this value does not indicate a complication of magnesium sulfate administration. Decreased urine output could suggest kidney injury, which is a potential complication of magnesium sulfate, but 70 ml/hour is within the normal range.
Correct Answer is C
Explanation
Choice A rationale:
Ribbon-like stools are more characteristic of conditions like irritable bowel syndrome (IBS) or colorectal cancer, not intussusception. Intussusception is a medical emergency where one segment of the intestine telescopes into another, leading to obstruction and potentially compromised blood flow.
Choice B rationale:
Hard stools positive for guaiac are suggestive of constipation and are not specific to intussusception. In intussusception, the stool characteristics are usually not relevant to the diagnosis as the condition primarily involves intestinal obstruction.
Choice C rationale:
"Currant jelly" stools are a classic characteristic of intussusception. These stools contain mucus and blood and have a characteristic appearance due to the compromised blood flow and tissue damage in the intestines. Recognizing this stool description is crucial for identifying a potential case of intussusception.
Choice D rationale:
Loose, foul-smelling stools are not specific to intussusception. These symptoms could be indicative of various gastrointestinal issues but are not directly associated with the classic presentation of intussusception, which involves the passage of bloody mucus in the stool.
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