Author Question: When performing an assessment of a patient, the nurse notices the presence of an enlarged right ... (Read 343 times)

cool · **on:** Jun 25, 2018

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?

a. Assess the patient's abdomen, and notice any tenderness.
b. Carefully assess the cervical lymph nodes, and check for any enlargement.
c. Ask additional health history questions regarding any recent ear infections or sore throats.
d. Examine the patient's lower arm and hand, and check for the presence of infection or lesions.

Question 2

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?

a. Lymph flow is propelled by the contraction of the heart.
b. The flow of lymph is slow, compared with that of the blood.
c. One of the functions of the lymph is to absorb lipids from the biliary tract.
d. Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.

lou · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.

Answer to Question 2

ANS: B
The flow of lymph is slow, compared with flow of the blood. Lymph flow is not propelled by the heart but rather by contracting skeletal muscles, pressure changes secondary to breathing, and contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves; therefore, flow is one way from the tissue spaces to the bloodstream.