The nurse is palpating an adult client's neck and does not note ...

[Bob-Dole]

The nurse is palpating an adult client's neck and does not note any palpable lymph nodes. Which conclusion by the nurse is appropriate based on this data?
 
  1. This finding indicates an infection.
  2. This finding is considered normal.
  3. This finding necessitates a referral to an ear, nose, and throat specialist.
  4. This finding indicates the need for further assessment to determine the malformation.

Question 2

The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term will the nurse use when documenting this finding?
 
  1. Bruit.
  2. Murmur.
  3. Stenosis.
  4. Occlusion.

[chjcharjto14]

Answer to Question 1

Correct Answer: 2
Lymph nodes of the head and neck are nonpalpable in adults. If an infection were present, the lymph nodes or the surrounding area may be tender and possibly enlarged. The lymph nodes that are located in the adult client's neck should not be able to be palpated. There is no reason to refer the client to a specialist or to inspect the client for further malformations in the neck because it is normal to be unable to palpate lymph nodes.

Answer to Question 2

Correct Answer: 1
A bruit can be heard through the bell of the stethoscope as a soft, blowing sound and is indicative of narrowing of the vessel. This is an abnormal sound. The sound described is not a murmur, which is heard when auscultating the heart, and the nurse should not document any conclusive diagnoses from assessment findings. Stenosis is a medical diagnosis. When an artery is stenosed, it can create a bruit. When a vessel is occluded, there is no associated sound because blood is not flowing through the vessel.