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 C
Explanation
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The correct answer is choice C. Visible peristalsis and weight loss.
Choice A rationale:
Abdominal rigidity and pain on palpation are not typically indicative of pyloric stenosis. These symptoms could be associated with a variety of other gastrointestinal conditions.
Choice B rationale:
A rounded abdomen and hypoactive bowel sounds are not specific to pyloric stenosis. These symptoms could be seen in various gastrointestinal disorders.
Choice C rationale:
Visible peristalsis and weight loss are classic symptoms of pyloric stenosis. The condition causes a narrowing of the opening from the stomach to the small intestine, preventing food from passing through. This leads to vomiting after feeding, persistent hunger, and weight loss since very little food passes to the small intestines.
Choice D rationale:
Distention of the lower abdomen and constipation are not typically indicative of pyloric stenosis. These symptoms could be associated with a variety of other gastrointestinal conditions.
Correct Answer is A
Explanation
Choice A rationale:
Ask her to turn to one side. The supine position during labor can compress the vena cava, reducing blood flow to the uterus and potentially compromising fetal oxygenation. Turning the woman to her side, especially the left side, can relieve this pressure and improve blood flow to the uterus, ensuring adequate oxygen supply to the fetus. This position change is crucial for the well-being of both the mother and the baby during labor.
Choice B rationale:
Elevate her feet and legs. Elevating the woman's feet and legs might not be effective in relieving the pressure on the vena cava, as it does not change the orientation of the uterus in relation to the vena cava. Turning the woman to her side is a more appropriate and effective action to improve blood flow to the uterus and fetus.
Choice C rationale:
Take her blood pressure. While monitoring the woman's blood pressure is essential during labor, it is not the most appropriate action in this situation. The priority is to relieve the compression of the vena cava by changing the woman's position.
Choice D rationale:
Determine whether fetal tachycardia is present. Monitoring the fetal heart rate is crucial during labor, but the woman's position should be the immediate concern if she is lying in the supine position. Changing her position to relieve the vena cava compression takes precedence to ensure adequate oxygenation to the fetus.
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