Which action by the nurse is appropriate when palpating the ...

[Awilson837]

Which action by the nurse is appropriate when palpating the client's lymph nodes during the physical assessment?
 
  1. Assessing each side separately.
  2. Applying gentle, circular pressure.
  3. Applying strong, deep pressure.
  4. Attempting to push the nodes into the muscle.

Question 2

The nurse is auscultating the thyroid gland and notes a bruit. Which conclusion by the nurse is appropriate based on this assessment finding?
 
  1. Stenosis of the thyroid artery.
  2. A normal finding.
  3. Indicates increased blood flow.
  4. Occurs with hypothyroidism.

[meganlapinski]

Answer to Question 1

Correct Answer: 2
Palpation of the lymph nodes should be done by exerting gentle, circular pressure using the finger pads of both hands. Strong, deep pressure can push the nodes into the muscle and underlying structures, making them difficult to find. Nodes should be palpated on both sides simultaneously for comparison. It is not appropriate to exhibit enough pressure to push the lymph nodes into the client's neck muscles because it makes it more difficult to find the lymph nodes.

Answer to Question 2

Correct Answer: 3

If the thyroid is enlarged, blood flows through the arteries at an accelerated rate, producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit. A bruit does not indicate stenosis, which is when blood flow is restricted through a blood vessel. This is not a normal finding. Hypothyroidism can produce a smaller than normal thyroid gland and decreased blood flow.