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:
Asthma. Rationale: A chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration are classic symptoms of asthma. Asthma is a chronic inflammatory condition of the airways characterized by bronchoconstriction, leading to symptoms such as wheezing, coughing, and shortness of breath. These symptoms often worsen during the expiratory phase of respiration, leading to the characteristic expiratory wheezing.
Choice B rationale:
Pneumonia. Rationale: Pneumonia is characterized by inflammation of the lung tissue and is often associated with productive cough, fever, chest pain, and sometimes wheezing. However, diffuse wheezing during the expiratory phase without significant productive cough is not a typical presentation of pneumonia.
Choice C rationale:
Bronchiolitis. Rationale: Bronchiolitis, caused by viruses such as RSV, commonly affects infants and young children. It presents with symptoms such as cough, wheezing, and respiratory distress. However, bronchiolitis typically involves lower airway inflammation and is often associated with viral upper respiratory symptoms. The presented case, with a chronic, nonproductive cough and diffuse wheezing during the expiratory phase, is more indicative of asthma.
Choice D rationale:
Foreign body in the trachea. Rationale: A foreign body in the trachea can cause acute respiratory distress and coughing. While it can lead to wheezing, the chronic nature of the symptoms described in the scenario (chronic, nonproductive cough and diffuse wheezing during the expiratory phase) is not consistent with a foreign body in the trachea.
Correct Answer is D
Explanation
Choice A rationale:
Facilitate maternal-newborn interaction. Facilitating maternal-newborn interaction is an important aspect of breastfeeding, but it is not the primary purpose of encouraging breastfeeding immediately after an emergency birth. The primary purpose is to initiate the lactation cycle, allowing the newborn to receive essential colostrum, the first milk rich in antibodies and nutrients, which aids in the development of the newborn's immune system.
Choice B rationale:
Stimulate the uterus to contract. While breastfeeding can stimulate uterine contractions due to oxytocin release, the primary purpose of encouraging breastfeeding in this context is not to contract the uterus but to initiate the lactation cycle for the newborn's benefit.
Choice C rationale:
Prevent neonatal hypoglycemia. Breastfeeding can help prevent neonatal hypoglycemia by providing the newborn with a constant supply of nutrients, but the primary purpose immediately after an emergency birth is to initiate the lactation cycle and provide colostrum, not solely to prevent hypoglycemia.
Choice D rationale:
Initiate the lactation cycle. Initiating the lactation cycle is the correct answer because breastfeeding immediately after birth helps the woman's body start producing milk and provides the newborn with colostrum, essential for their health and development. Colostrum is rich in antibodies and nutrients, offering vital protection and nourishment to the newborn.
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