The nurse is performing an assessment on a healthy preschool-age ...

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The nurse is performing an assessment on a healthy preschool-age client and palpates two enlarged lymph nodes on the child's neck. The lymph nodes are soft, mobile, nontender, and each is less than 1 cm in diameter.
 
  Which action by the nurse is the most appropriate?
  1. Assess for an infected wound.
  2. Document this as a normal finding.
  3. Notify the healthcare provider.
  4. Obtain an order for a throat culture.

Question 2

The nurse is performing a peripheral vascular assessment of a female client who is 7 months pregnant. The nurse notes mild peripheral edema, all other findings were normal. Which action by the nurse is appropriate based on this assessment data?
 
  1. Notify the healthcare provider immediately regarding this abnormal finding.
  2. Obtain an order from the healthcare provider for a diuretic to reduce the client's edema.
  3. Document the findings as expected due to the client's pregnancy.
  4. Educate the client regarding ways to reduce the risk about peripheral vascular ulcer development.

[parshano]

Answer to Question 1

Correct Answer: 2
It is a normal finding to determine that a child has several enlarged lymph nodes less than 1cm such as these. When lymph nodes are significantly enlarged, greater than 1cm, the nurse should assess the child for an infection. Documenting this as a normal finding is appropriate since these enlarged lymph nodes are small, less than 1cm, nontender, and mobile. It is not necessary for the nurse to notify the healthcare provider at this time. Obtaining an order for a throat culture would be an appropriate nursing action if the child had significantly enlarged lymph nodes and evidence that an infection was present in the child's pharynx.

Answer to Question 2

Correct Answer: 3
Pressure from the uterus on the lower extremities can obstruct venous return and can cause edema, varicosities of the leg, and hemorrhoids. Mild peripheral edema is an expected finding when a pregnant client is in her third trimester. The client's healthcare provider does not need to be immediately notified. The client does not need a diuretic to reduce the mild peripheral edema. This client is not necessarily at a greater risk for developing a peripheral vascular ulcer.