Question 1

During an assessment, the nurse notes enlargement and tenderness of the right preauricular lymph nodes. This finding would suggest the need for additional assessment of which areas?. Select all that apply.

Accepted Answer

The preauricular lymph nodes drain areas of the face and head, so enlargement and tenderness in these nodes suggest the need for further assessment of these areas.

Question 2

Which lymph node assessment findings would increase the nurse's concern that a patient has a malignancy?. Select all that apply.

Accepted Answer

Tender, movable, and easily palpable lymph nodes are often indicative of benign conditions, while hard, irregularly shaped nodes are more concerning for malignancy.

Question 3

A patient is admitted for an infected leg wound. The nurse notes that the patient's band count on the CBC and differential is elevated. How does the nurse interpret this information?

Accepted Answer

An elevated band count on the CBC and differential can indicate an ongoing infection and the development of sepsis. This finding warrants further assessment and intervention to prevent the progression of the infection. Options A, C, and D are not supported by an elevated band count.

Question 4

A patient has a skin infection over the inner aspect of the left thigh. The nurse would anticipate finding enlargement when palpating which lymph nodes?. Select all that apply.

Accepted Answer

The lymphatic drainage from the lower limbs, including the inner aspect of the thigh, primarily flows to the inguinal lymph nodes. This includes both the superior and inferior inguinal lymph nodes. Therefore, if there's an infection in the inner aspect of the left thigh, enlargement could be expected in these nodes due to their role in filtering and draining lymph from that area. Preauricular, supraclavicular, and axillary nodes are not directly involved in draining the lower limbs, so they would not typically be enlarged due to an infection in the thigh.

Question 5

Review of a patient's medical record reveals the presence of petechiae. How would the nurse interpret this information?. Select all that apply.

Accepted Answer

Petechiae are small purple or red spots that appear on the skin as a result of bleeding underneath the skin. They are caused by damage to capillary blood vessels, and are not related to a rash or infection distal to the point where the petechiae begin. Petechiae do not indicate trauma or bruising, but rather bleeding under the skin.

Question 6

A patient has dysfunction of immunity associated with Peyer's patches. The nurse interprets this information to indicate a disorder of which areas?. Select all that apply.

Accepted Answer

Peyer's patches are lymphoid tissue located in the small intestine that make up a significant part of gut-associated lymphoid tissue (GALT). Dysfunction of immunity associated with Peyer's patches indicates a disorder of the intestines and GALT. The spleen, axilla, and lungs are not directly associated with Peyer's patches.

Question 7

While percussing a patient's left lung, the nurse detects a dull percussion note. How would the nurse interpret this finding?

Accepted Answer

A dull percussion note during lung percussions can indicate the presence of fluid or consolidation in the lung tissue, which could be a sign of infection or other pulmonary conditions. Hepatomegaly, emphysema, or normal lung tissue would not typically produce a dull percussion note.

Question 8

Which assessment findings would the nurse evaluate as indicating inflammation or infection of the superficial lymph nodes?. Select all that apply.

Accepted Answer

Inflammation or infection of the superficial lymph nodes is characterized by edema, easily palpable nodes, and visible contour of the lymph node.

Question 9

The nurse would consider a provisional diagnosis of sepsis as supported by a band count of over ______ % of the total white blood cell count.

Accepted Answer

The answer of The nurse would consider a provisional diagnosis...

Quiz 52: Nursing Management of the Patient With Immunological and Inflammatory Disorders