The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?
Explanation & Rationale
A. Ask the client about any localized tenderness at the site. Enlarged lymph nodes can indicate infection, inflammation, or malignancy. Assessing for tenderness helps differentiate between reactive lymphadenopathy (which is often tender) and potentially more concerning causes like malignancy (which is usually non-tender and hard). B. Auscultate the lymph node for the presence of a bruit. Lymph nodes do not typically produce bruits. If a bruit is suspected, the nurse should auscultate the carotid artery or consider the possibility of an abnormal vascular structure, such as an arteriovenous malformation. C. Record this normal finding in the assessment record. While small, non-tender lymph nodes can sometimes be normal, an enlarged, visible lymph node is not considered a normal finding and requires further assessment. D. Cover the inflamed area and notify the healthcare provider. Lymph node enlargement does not require covering unless there is an open wound or drainage. While notifying the provider may be necessary in some cases, further assessment is the priority before escalation.